Matthew A. Clark

Cancer of the anal canal.

Anal cancer is an uncommon tumour that represents 4% of all cancers of the lower gastrointestinal tract. Its pathogenesis and treatment have undergone substantial reassessment over the past two decades, and this is likely to continue. Anal cancer can be cured by synchronous chemoradiotherapy, a treatment that both enables anal continence to be retained and reserves abdominoperineal resection of the rectum and anal canal (with formation of a permanent colostomy) for recurrent or residual disease after primary chemoradiotherapy. Overall, survival from anal cancer is now around 70-80% at 5 years. Future challenges will be influenced by an increasing incidence due to human papillomavirus and HIV infection, more accurate characterisation and treatment of early (in situ) disease, and optimisation of chemoradiation regimens.

Surgical management of primary and recurrent retroperitoneal liposarcoma.

Surgery plays a dominant role in the initial and subsequent treatment of retroperitoneal liposarcoma (RPLS). This study was a review of outcomes of patients treated at the Royal Marsden Hospital.

Isolated Limb Perfusion With Melphalan and Tumor Necrosis Factor α for Advanced Melanoma and Soft-Tissue Sarcoma

BackgroundIsolated limb perfusion (ILP) with melphalan is used in the treatment of advanced in-transit melanoma but has no real efficacy for irresectable soft tissue sarcomas arising in the extremities. The addition of tumor necrosis factor (TNF)-α may increase response rates for bulky melanoma and for sarcoma, but the potential for major systemic toxicity has limited its use.MethodsBetween October 2000 and April 2004, 49 ILPs were performed with melphalan and TNF-α. All procedures were performed with continuous leakage monitoring and regional hyperthermia.ResultsForty-nine ILPs were performed for melanoma (n = 30), sarcoma (n = 16), or other tumors (n = 3). The most common indications were widespread in-transit disease for melanoma (n = 29) and irresectable primary disease for sarcoma (n = 9). Complete and partial responses for melanoma were 40% and 37%, and for sarcoma they were 20% and 33%. At a median follow-up of 14 months, 66% of melanoma patients who responded had not experienced local progression, compared with only 37% of sarcoma patients. Progression-free survival was significantly less for patients with sarcoma than melanoma (P = .0476). Four of 16 patients with sarcoma subsequently required amputation for progressive disease.ConclusionsILP with melphalan and TNF-α is a valuable treatment for advanced in-transit melanoma. Significant response rates were also seen in irresectable sarcoma, although the duration of response was limited.

Management of in‐transit metastases from cutaneous malignant melanoma

In‐transit metastases from cutaneous malignant melanoma (cutaneous or subcutaneous deposits between the primary melanoma and regional lymph nodes) represent late‐stage disease, and their treatment should be tailored accordingly. This article reviews the pathology, clinical significance and treatment options for in‐transit disease from melanoma.

Amputation for soft-tissue sarcoma

Soft-tissue sarcomas are a group of rare malignant tumours, many of which arise in the limbs. Most are treated with a combination of wide local excision and radiotherapy, but a small number--including proximal, large, high-grade, or recurrent tumours, or those involving major neurovascular structures--necessitate major amputation including forequarter or hindquarter amputation. These uncommon operations should remain in the surgical armamentarium for carefully selected patients. Those being considered for amputation should be referred to a tertiary sarcoma unit for examination of all other options, such as limb-salvage surgery, tumour downstaging with chemotherapy or radiotherapy (perhaps with subsequent limb-salvage surgery), or novel techniques such as isolated limb perfusion. Only after careful assessment should amputation be carried out. Outcomes after major amputation are highly variable, but such procedures can confer useful palliation to patients with distressing symptoms (pain, bleeding, fungation), long-term disease-free survival with reasonable function in carefully selected patients, and cure in some.

Major amputation for soft-tissue sarcoma†

Advances in oncological practice have reduced the number of major amputations performed for soft‐tissue sarcoma, but this remains a valuable, if infrequent, option for both curative and palliative indications.

Surgery for gastrointestinal stromal tumour in the post-imatinib era

Gastrointestinal stromal tumour (GIST) is a rare tumour. Historically, surgery has been the only effective treatment. The prognosis of patients with gastrointestinal stromal tumour is poor. Even after apparently ‘curative’ surgical resection more than 50% of patients relapse. The development of an effective novel targeted therapy against GIST (imatinib mesylate) is a success story of molecular biology that has dramatically altered the management of patients with these tumours. However, as follow up of patients who have initially responded to imatinib has increased, it has become evident that such hopes of cure were premature because responses to imatinib are of limited duration. Unresolved issues include the role of imatinib as an induction (neo‐adjuvant) therapy prior to surgery, or as adjuvant treatment after surgery, the role of surgery in patients with a differential or partial response and the role of surgery in patients with isolated metastatic disease. In the present paper the biology and natural history of GIST are reviewed, and the complexities of surgical management that exist in the context of an effective, but not curative, biological therapy, are addressed.

Dr. Herbert Lumley Snow, MD, MRCS (1847–1930): The Original Champion of Elective Lymph Node Dissection in Melanoma

Herbert Snow (1847–1930), a London surgeon with a particular interest in melanoma, was a controversial proponent of anticipatory gland excision well before acceptance of elective lymph node dissections. This article describes the work of Snow within a wider historical context.Herbert Snow (1847–1930), a London surgeon with a particular interest in melanoma, was a controversial proponent of anticipatory gland excision well before acceptance of elective lymph node dissections. This article describes the work of Snow within a wider historical context.

Kimura's Disease: Upper limb involvement in a Pacific Island man

We report the case of a 48-year-old Pacific Island (Samoan) man, with no known Chinese ancestry, with a large solitary subcutaneous soft-tissue swelling of the upper arm. The clinical differential diagnosis included benign and malignant soft-tissue tumours such as a lipoma or liposarcoma. Microscopically the lesion showed features of Kimura’s disease, the first time this has been described in this race. The Samoan population of New Zealand numbers 101 754 people and constitutes approximately 6% of Auckland’s total population. 1

CR08 ONE YEAR EXPERIENCE WITH FAST‐TRACK SURGERY FOR ELECTIVE COLONIC RESECTION

Purpose  Fast‐Track Surgery or Enhanced Recovery After Surgery (ERAS) programs are becoming increasingly common. However there are concerns regarding safety, readmission rates and the impact on overall morbidity. We aimed to compare the results from our ERAS program for elective colonic surgery with those from our institution prior to commencement of ERAS.