Gary N. Mann

Less Is (Usually) More: When Is Amputation Appropriate for Treatment of Extremity Soft Tissue Sarcoma?

Limb-salvage surgery, combining wide excision and radiotherapy, is the standard of treatment for patients with extremity soft tissue sarcoma. In the only randomized study comparing amputation with limb preservation, Rosenberg et al. demonstrated that despite slightly higher local recurrence rates, limb salvage was not detrimental to patient survival. This is a common finding in solid tumor biology: organ preservation is not associated with worse overall survival, even though patients often have more local recurrences. Indeed, breast-conservation therapy is preferred over mastectomy and has been proven to be as effective in multiple randomized studies. We also see this, for example, in such diverse tumors as laryngeal cancer and anorectal melanoma. This trend of ‘‘less is more’’ in surgery is well founded and leads to improved patient satisfaction and quality of life (QOL) without compromising quantity of life. In this issue of Annals of Surgical Oncology, Ghert et al. 5 from the Princess Margaret Hospital present a series of patients undergoing amputation as the primary surgical procedure for treatment of extremity soft tissue sarcoma. In their prospective database, they found that only 6% of patients (25 of 413) required amputation as initial surgical treatment. This is in keeping with data from other institutions, where the rates of initial amputation have decreased from approximately 40% to approximately 5% as more effective surgical and oncological strategies evolve and as our understanding of the natural history of these malignancies improves. There is still a role for amputation, and in this series there were three major indications: (1) anticipated inadequate limb function after wide excision, (2) multicompartmental neurovascular tumor involvement, and (3) local tumor contamination from unplanned prior surgery. Although local recurrences were not discussed in either patient group, one would expect lower rates of local relapse in those undergoing amputation. Despite this expectation, on univariate analysis, patients undergoing amputation had higher rates of systemic relapse, which on multivariate analysis was accounted for by the larger tumor size in these patients. As alluded to previously, more radical surgery does not seem to improve survival. With this in mind, the limits of limb-sparing surgery are pushed to their maximum. Larger and deeper tumors undergo wide excision and no longer require anatomical compartmental resection unless this is dictated by tumor location. Radiotherapy plays a key role in the local control of the tumor. It too is the subject of vigorous investigation of the optimal timing and dose and the effects on patient outcome and satisfaction. For example, patients treated with postoperative radiation have fewer wound complications than those treated before surgery. Despite improved early functional status in those irradiated after surgery, outcomes ultimately seem equivalent. These issues are not mundane. If we are to offer patients less surgery, anticipating equivalent survival but better QOL outcomes, then we need to be mindful of the alternatives and the consequences of the treatment prescribed for their care. Many surgeons consider amputation if sacrifice of the sciatic nerve is required. However, we have shown, in the Received September 27, 2004; accepted October 18, 2004. Address correspondence and reprint requests to: Gary N. Mann, MD; E-mail: gnmann@u.washington.edu.

[11C]Metahydroxyephedrine and [18F]fluorodeoxyglucose positron emission tomography improve clinical decision making in suspected pheochromocytoma

BackgroundPheochromocytomas are rare tumors of chromaffin cells for which the optimal management is surgical resection. Precise diagnosis and localization may be elusive. We evaluated whether positron emission tomography (PET) scanning with the combination of [18F]fluorodeoxyglucose (FDG) and the norepinephrine analogue [11C]metahydroxyephedrine (mHED) would allow more exact diagnosis and localization.MethodsFourteen patients with suspected pheochromocytoma were evaluated by anatomical imaging (computed tomography or magnetic resonance imaging) and [131I]metaiodobenzylguanidine (MIBG) planar imaging. PET imaging was performed by using mHED with dynamic adrenal imaging, followed by a torso survey and FDG with a torso survey. Images were evaluated qualitatively by an experienced observer.ResultsEight patients had pathology-confirmed pheochromocytoma. Of the other six, two patients had normal adrenal tissue at adrenalectomy, and the other four had subsequent clinical courses inconsistent with a diagnosis of pheochromocytoma. In four of eight patients with pheochromocytoma, MIBG failed to detect one or more sites of pathology-confirmed disease. The mHED-PET detected all sites of confirmed disease, whereas FDG-PET detected all sites of adrenal and abdominal disease, but not bone metastases, in one patient. MIBG and FDG-PET results were all negative in the six patients without pheochromocytoma. One patient with adrenal medullary hyperplasia had a positive mHED-PET scan. PET scanning aided the decision not to operate in three of six patients. The resolution of PET functional imaging was superior to that of MIBG.ConclusionsPET scanning for pheochromocytoma offers improved quality and resolution over current diagnostic approaches. PET may significantly influence the clinical management of patients with a suspicion of these tumors and warrants further investigation.

Primary leiomyosarcoma of the inferior vena cava: A 2-institution analysis of outcomes

BACKGROUND Approximately 300 cases of leiomyosarcoma of the inferior vena cava (IVC) have been reported in the literature to date. In this study, we combined the experience from 2 institutions to provide additional clinical outcomes data. METHODS We performed a retrospective analysis from 1984 to 2009 that included 17 patients treated between the 2 institutions. Clinicopathologic data, surgical and adjuvant therapy, and survival outcomes were obtained. RESULTS The median age of patients in the study was 48 years. The tumor location was infrarenal in 8 patients, juxtarenal in 6, and suprahepatic in 2 patients; 7 patients had high-grade tumors. All patients underwent complete resection; the IVC was repaired primarily in 5 patients, ligated in 5, and reconstructed with a prosthetic tube graft in 7 patients. There was no perioperative mortality; 6 patients had complications. Median follow-up was 49 months; median survival had not been reached when this paper was written. The 5-year overall and disease -free survival were 56% and 37%, respectively. Of the 17 patients, 10 experienced disease recurrence and underwent numerous treatment modalities for these recurrences. CONCLUSION Aggressive resection of primary leiomyosarcoma of the IVC can be performed safely and result in long-term survival, irrespective of IVC management. Despite high recurrence rates, no consensus yet exists regarding adjuvant treatment.

Expanding Resident Conferences While Tailoring Them to Level of Training: A Longitudinal Study

OBJECTIVE To evaluate the effect of changing a 1-hour weekly all-resident didactic conference to an expanded 4-hour bimonthly level-specific didactic conference. DESIGN Prospective outcome measures included an anonymous 10-item perceptions survey administered at 4 time points (preintervention, 6 months postintervention, 1 year postintervention, and 2 years postintervention), mean attendance rates preintervention and postintervention, and mean ABSITE scores preintervention and postintervention. SETTING Large university-based surgical residency. PARTICIPANTS Surgical residents (R1-R5, n = 75) were divided into junior (R1-R3, n = 56) and senior (R4-R5, n = 19) groups. Each group attended a session every other Wednesday. RESULTS Significant improvements were observed in overall resident satisfaction (55% vs 80%, p < 0.005) and level-specific appropriateness of content (81% vs 94%, p < 0.001). Furthermore, resident attendance rates were improved substantially (33% vs 55%, p < 0.001). ABSITE scores were not affected significantly by the change in curriculum structure. CONCLUSIONS An expanded, bimonthly level-specific didactic curriculum is more effective than a shorter, weekly all-resident conference as evidenced by resident attitudes and attendance. Additional benefits of the alternating schedule include a reduced number of residents in each conference and the availability of residents for clinical educational activities (eg, operative cases or clinic). Expanded educational time has allowed the introduction of nontraditional topics that include leadership, communication, practice management, professionalism, and technical skills training.

Recurrence patterns of retroperitoneal leiomyosarcoma and impact of salvage surgery

Optimal treatment strategies for retroperitoneal leiomyosarcoma (RPLMS), particularly recurrent disease, are unknown.

Erratum: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin: A consensus statement (Annals of Surgical Oncology 14 (128-133)DOI: 10.1245/s10434-006-9185-7)

J. Esquivel, R. Sticca, P. Sugarbaker, E. Levine, T. D. Yan, R. Alexander, D. Baratti, D. Bartlett, R. Barone, P. Barrios, S. Bieligk, P. Bretcha-Boix, C. K. Chang, F. Chu, Q. Chu, S. Daniel, E. deBree, M. Deraco, L. Dominguez-Parra, D. Elias, R. Flynn, J. Foster, A. Garofalo, F. N. Gilly, O. Glehen, A. Gomez-Portilla, L. Gonzalez-Bayon, S. Gonzalez-Moreno, M. Goodman, V. Gushchin, N. Hanna, J. Hartmann, L. Harrison, R. Hoefer, J. Kane, D. Kecmanovic, S. Kelley, J. Kuhn, J. LaMont, J. Lange, B. Li, B. Loggie, H. Mahteme, G. Mann, R. Martin, R. A. Misih, B. Moran, D. Morris, L. Onate-Ocana, N. Petrelli, G. Philippe, J. Pingpank, A. Pitroff, P. Piso, M. Quinones, L. Riley, L. Rutstein, S. Saha, S. Alrawi, A. Sardi, S. Schneebaum, P. Shen, D. Shibata, J. Spellman, A. Stojadinovic, J. Stewart, J. Torres-Melero, T. Tuttle, V. Verwaal, J. Villar, N. Wilkinson, R. Younan, H. Zeh, F. Zoetmulder, and G. Sebbag

Multiply recurrent retroperitoneal liposarcoma

Retroperitoneal liposarcomas (RPLPS) are rare tumors that represent at least 50% of all retroperitoneal sarcomas. Surgical resection remains the standard of care. Unfortunately, many RPLPS patients will develop a local recurrence and subsequently die in the absence of distant metastasis. This review outlines the factors that predict local recurrence and influence the management of first and subsequent multiply recurrent RPLPS.

High‐quality results of cytoreductive surgery and heated intraperitoneal chemotherapy perfusion for carcinomatosis at a low volume institution

Maximal cytoreductive surgery (CS) with heated intraperitoneal chemotherapy perfusion (HIPEC) for peritoneal carcinomatosis can improve oncologic outcomes, but is associated with significant morbidity. Whether low‐volume experience with CS/HIPEC results in acceptable outcomes is unknown.

Multiple liver abscess formation and primary gastrointestinal stromal tumor

Gastrointestinal stromal tumors are the most common mesenchymal tumors of the gastrointestinal tract. The introduction of a number of small molecule tyrosine kinase inhibitors has revolutionized the management of metastatic disease. Surgery is the mainstay of management for localized disease. Patients with high risk tumors are treated with adjuvant imatinib. We report the rare presentation of a localized primary small bowel gastrointestinal stromal tumor in association with multiple liver abscesses. Cystic liver lesions should be fully evaluated in gastro intestinal tumor patients to exclude an infective cause. Treatment with intravenous antibiotics resulted in clinical and radiological improvement of the liver abscesses. The small bowel tumor was treated with surgical resection.

Concomitant organ resection does not improve outcomes in primary retroperitoneal well-differentiated liposarcoma: A retrospective cohort study at a major sarcoma center

We investigated whether concomitant organ removal as part of the primary resection of RP WDLPS confers an outcome advantage in patients treated at a major sarcoma center.