Completion surgery vs. primary TME for early rectal cancer: a national study

Purpose While local excision by transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) is an option for low-risk early rectal cancers, inaccuracies in preoperative staging may be revealed only upon histopathological evaluation of the resected specimen, demanding completion surgery (CS) by formal resection. The aim of this study was to evaluate the results of CS in a national cohort. Method This was a retrospective analysis of national registry data, identifying and comparing all Norwegian patients who, without prior radiochemotherapy, underwent local excision by TEM or TAMIS and subsequent CS, or a primary total mesorectal excision (pTME), for early rectal cancer during 2000–2017. Primary endpoints were 5-year overall and disease-free survival, 5-year local and distant recurrence, and the rate of R0 resection at completion surgery. The secondary endpoint was the rate of permanent stoma. Results Forty-nine patients received CS, and 1098 underwent pTME. There was no difference in overall survival (OR 0.73, 95% CI 0.27–2.01), disease-free survival (OR 0.72, 95% CI 0.32–1.63), local recurrence (OR 1.08, 95% CI 0.14–8.27) or distant recurrence (OR 0.67, 95% CI 0.21–2.18). In the CS group, 53% had a permanent stoma vs. 32% in the pTME group (P = 0.002); however, the difference was not significant when adjusted for age, sex, and tumor level (OR 2.17, 0.95–5.02). Conclusions Oncological results were similar in the two groups. However, there may be an increased risk for a permanent stoma in the CS group.

Salvage hysterectomy after radiotherapy for cervical cancer: literature review

Recurrent cervical cancer is a difficult challenge for gynecological oncologist. In this paper we review papers concerning incidence and surgical treatment of pelvic recurrences. A point of interest is studies evaluating completion surgery after radiotherapy/chemoradiotherapy. Surgery after definitive radiotherapy is associated with high morbidity and should be performed only in patients with residual tumor. Magnetic resonance imaging in special regimen can be useful in detecting residual disease.

Targeted use of intraoperative frozen-section analysis lowers the frequency of completion thyroidectomy

Background The impact of intraoperative frozen section (iFS) analysis on the frequency of completion thyroidectomy for the management of thyroid carcinoma is controversial. Although specialized endocrine centres have published their respective results, there are insufficient data from primary and secondary healthcare levels. The aim of this study was to analyse the utility of iFS analysis. Methods In the Prospective Evaluation Study Thyroid Surgery (PETS) 2 study, 22 011 operations for benign and malignant thyroid disease were registered prospectively in 68 European hospitals from 1 July 2010 to 31 December 2012. Group 1 consisted of 569 patients from University Medical Centre (UMC) Mainz, and group 2 comprised 21 442 patients from other PETS 2 participating hospitals. UMC Mainz exercised targeted but liberal use of iFS analysis for suspected malignant nodules. iFS analysis was compared with standard histological examination regarding the correct distinction between benign and malignant disease. The percentage of completion thyroidectomies was assessed for the participating hospitals. Results iFS analysis was performed in 35.70 per cent of patients in group 1 versus 21.80 per cent of those in group 2 (risk ratio (RR) 1.6, 95 per cent c.i. 1.5 to 1.8; P < 0.001). Sensitivity of iFS analysis was 75.0 per cent in group 1 versus 63.50 per cent in group 2 (RR 1.2, 1.2 to 1.3; P = 0.040). Completion surgery was necessary in 8.10 per cent of patients in group 1 versus 20.8 per cent of those in group 2 (RR 0.4, 0.2 to 0.7; P = 0.001). Conclusion iFS analysis is a useful tool in determining the appropriate surgical management of thyroid disease. Targeted use of iFS was associated with a significantly higher sensitivity for the detection of malignancy, and with a significantly reduced necessity for completion surgery.

Re-staging surgery in endometrial cancer: an audit on its value

Background: Incomplete surgical staging in carcinoma endometrium is not an uncommon entity in developing world. Proper surgical staging has got a role in prognostication and planning adjuvant treatment. So, an audit was done to assess the extent of upstaging in women with endometrial cancers who were referred to index centre from outside hospitals with incomplete surgical staging.Methods: It is a retrospective study. The demographic, clinical and treatment details of women with complete data having at-least one follow up after completion surgery were analyzed. Patients who had any other anticancer treatment elsewhere were excluded. The extent of upstaging was studied based on International federation of gynecology and obstetrics (FIGO) 2008 staging.Results: A total of 88 patients of endometrial cancer were evaluated retrospectively, of which 10 had completion surgery. 10% of the patients were upstaged according to the FIGO stage (one from IA to IB), while one patient upstaged from IIIA to IVB after slide review by index centre. According to FIGO Grade, 40% patient upgraded (one upgraded from I to II, three from II to III) while one downgraded from II to I. Recurrence rate was 40%.Conclusions: Upstaging is seen in 10% of patient after completion surgery, which requires the necessity of evaluation by gynecologic oncologist selectively. However, larger and multi-centric studies needed to draw definite conclusion. There is a significant discordance in grade and histology after the review at index centre.

Clinical Outcomes Observation in Stage IIB–III Cervical Cancer Treated by Adjuvant Surgery Following Concurrent Chemoradiotherapy

Objective: To explore the feasibility of adjuvant surgery following concurrent chemoradiation therapy (CCRT) in stage ⅡB–Ⅲ cervical cancer. And analyze risk factors of recurrence after surgery. Methods: Forty-nine patients diagnosed with stage ⅡB–Ⅲ cervical cancer were reviewed retrospectively. Investigated the risk factors of recurrence after surgery using Chi-squared Test and further analyzed multiple factors affecting postoperative recurrence using the multi-factor logistic regression. Furthermore, the correlation of surgery outcomes (including operation time, bleeding, and hospitalization date and surgery complications) with the time which carried out between CCRT and completion surgery was analyzed. Results: Tumor histology and residual tumor in the cervix were significantly associated with postoperative recurrence (P = 0.014 and P = 0.040, respectively). Logistic regression analysis demonstrated that the independent risk factors of postoperative recurrence were age and residual tumor in the cervix (P = 0.017 and P = 0.030, respectively). Compared with completion surgery was carried out ≤ 6 weeks after CCRT, the operation time, bleeding, hospitalization date and surgery complications were more than > 6 weeks group. Moreover, bleeding and surgery complications were statistically significant (P = 0.019 and P = 0.044, respectively). Conclusion: CCRT combined surgery for stage ⅡB–Ⅲ cervical cancer was feasible, reduced the rate of postoperative recurrence and surgery complications were tolerated. CCRT combined surgery might improve the local control of lesion.