Nir Wasserberg

Applicability of the Sentinel Node Technique to Merkel Cell Carcinoma

Background. Merkel cell carcinoma (MCC) resembles malignant melanoma in several ways. Both are cutaneous lesions of the same embryonic origin. Both have an unpredictable biologic behavior, early regional lymph node involvement, early distant metastases, and high recurrence rate. Objective. To apply the sentinel node technique described for melanoma to MCC in light of the common biologic features of these two tumors. Methods. Preoperative lymphoscintigraphy, intraoperative lymphatic mapping, and sentinel node biopsy and frozen section histology were performed to guide the surgical treatment of three patients with MCC. Results. Application of this approach in patients with MCC is feasible, reproducible, and seems reliable. Conclusion. The use of the sentinel node technique for MCC will reduce the number of unnecessary lymphadenectomies, will enable identification of microscopic metastases to lymph nodes, and will improve the stratification and accrual of patients into adjuvant treatment protocols. It may even lead to a survival benefit.

Effect of surgically induced weight loss on pelvic floor disorders in morbidly obese women.

Objective:To evaluate the effect of surgically induced weight loss on pelvic floor disorders (PFD) in morbidly obese women. Summary Background Data:Although bariatric surgery may lead to the improvement of some obesity-related comorbidities, the resolution of global PFD has not been well described. Methods:Women with a body mass index (BMI) of 35 kg/m2 or more who were considering bariatric surgery were asked to complete 2 validated condition-specific questionnaires assessing the distress/quality of life impact of PFD, total and by domain (pelvic organ prolapse, colorectal-anal, and urogenital). Women who achieved a ≥50% excess body weight loss after surgery were asked to complete the same questionnaires for comparison. Results:Of the 178 women who underwent surgery, 46 completed the postoperative questionnaires. Mean age of this group was 45 years (range, 20–67), and mean preoperative BMI was 45 kg/m2 (range, 35–75). The prevalence of PFD symptoms improved from 87% before surgery to 65% after surgery (P = 0.02, 95% CI: 0.05%–53%). There was a significant reduction in total mean distress scores after surgery (P = 0.015, 95% CI: 3.3–32.9), which was attributed mainly to the significant decrease in urinary symptoms (P = 0.0002, 95% CI: 8.2–22.7). Reductions in the scores were noted for the other PFD domains as well. Quality of life total scores improved (P = 0.002, 95% CI: 4.8–27.1), as did scores in the urinary domain (P = 0.0005, 95% CI: 3.8–13.5) and the pelvic organ prolapse domain (P = 0.015, 95% CI: 0.6–9.5). Age, parity, history of complicated delivery, percent excess body weight loss, BMI, type of weight loss procedure and presence of diabetes mellitus and hypertension had no predictive value for postoperative outcomes. Conclusion:Surgically induced weight loss has a beneficial effect on symptoms of PFD in morbidly obese women.

Early prediction of histopathological response of rectal tumors after one week of preoperative radiochemotherapy using 18 F-FDG PET-CT imaging. A prospective clinical study

BackgroundPreoperative radiochemotherapy (RCT) is standard in locally advanced rectal cancer (LARC). Initial data suggest that the tumor’s metabolic response, i.e. reduction of its 18 F-FDG uptake compared with the baseline, observed after two weeks of RCT, may correlate with histopathological response. This prospective study evaluated the ability of a very early metabolic response, seen after only one week of RCT, to predict the histopathological response to treatment.MethodsTwenty patients with LARC who received standard RCT regimen followed by radical surgery participated in this study. Maximum standardized uptake value (SUV-MAX), measured by PET-CT imaging at baseline and on day 8 of RCT, and the changes in FDG uptake (ΔSUV-MAX), were compared with the histopathological response at surgery. Response was classified by tumor regression grade (TRG) and by achievement of pathological complete response (pCR).ResultsAbsolute SUV-MAX values at both time points did not correlate with histopathological response. However, patients with pCR had a larger drop in SUV-MAX after one week of RCT (median: -35.31% vs −18.42%, p = 0.046). In contrast, TRG did not correlate with ΔSUV-MAX. The changes in FGD-uptake predicted accurately the achievement of pCR: only patients with a decrease of more than 32% in SUV-MAX had pCR while none of those whose tumors did not show any decrease in SUV-MAX had pCR.ConclusionsA decrease in ΔSUV-MAX after only one week of RCT for LARC may be able to predict the achievement of pCR in the post-RCT surgical specimen. Validation in a larger independent cohort is planned.

Radiation therapy for prostate cancer increases the risk of subsequent rectal cancer.

Purpose:To assess whether radiation therapy for prostate cancer (PCa) increases the risk of metachronous rectal cancer (RCa) and compare outcomes of RCa after radiation therapy and surgery. Patients and Methods:The Israel Cancer Registry was queried to identify patients with PCa and RCa diagnosed between 1982 and 2005. The age adjusted standardized incidence ratio (SIR) of RCa was defined as the ratio between the observed and expected (calculated) RCa cases and compared among the following: overall Israeli male population, patients with PCa treated with radiation therapy, patients with PCa treated surgically. The medical records of men diagnosed with RCa were reviewed and clinical characteristics retrieved. Results:Of 29,593 men diagnosed with PCa, 2163 were treated with radiation therapy, 6762 were treated surgically and 20,068 patients were treated with either primary androgen deprivation therapy or offered watchful waiting. Of the entire study cohort, 194 (0.65%) patients were diagnosed with subsequent RCa. Compared to the overall male population and stratified by treatment modality, the risk of developing RCa after radiation therapy was significantly increased (SIR = 1.81, 95% CI 1.2–2.5), whereas it was not increased in those managed by surgery (SIR = 1.22, 95% CI 0.85–1.65). RCa after radiation therapy was diagnosed at a more advanced stage, translating into inferior disease specific survival. Conclusions:Compared to men diagnosed with PCa managed by surgery, we observed an increased risk of RCa in patients treated with radiation therapy. Further studies are needed to validate these findings and assess whether routine colonoscopic surveillance is warranted after pelvic radiation.

Resection margins in modern rectal cancer surgery.

At present, the preferred treatment for rectal cancer is low anterior resection with total mesorectal excision and sphincter preservation. Complete removal of the tumors lymphatic and vascular pad with free resection margins has led to a reduction in rates of local recurrence and improved disease‐specific survival. In addition to the distal and proximal margins from the tumor edge, for an optimal outcome, it is essential to consider distal mesorectal spread and the circumferential mesorectal margin. J. Surg. Oncol. 2008;98:611–615.

Interval to surgery after neoadjuvant treatment for colorectal cancer.

The current standard treatment of low-lying locally advanced rectal cancer consists of chemoradiation followed by radical surgery. The interval between chemoradiation and surgery varied for many years until the 1999 Lyon R90-01 trial which compared the effects of a short (2-wk) and long (6-wk) interval. Results showed a better clinical tumor response (71.7% vs 53.1%) and higher rate of positive and pathologic tumor regression (26% vs 10.3%) after the longer interval. Accordingly, a 6-wk interval between chemoradiation and surgery was set to balance the oncological results with the surgical complexity. However, several recent retrospective studies reported that prolonging the interval beyond 8 or even 12 wk may lead to significantly higher rates of tumor downstaging and pathologic complete response. This in turn, according to some reports, may improve overall and disease-free survival, without increasing the surgical difficulty or complications. This work reviews the data on the effect of different intervals, derived mostly from retrospective analyses using a wide variation of treatment protocols. Prospective randomized trials are currently ongoing.

Third- and fourth-degree perineal tears--incidence and risk factors.

Abstract Objective: To assess the incidence and risk factors for third- and fourth-degree perineal tears (34DPT), and to identify subgroups of women who are at especially high risk for 34DPT. Methods: A cohort study of women who underwent vaginal delivery in a single tertiary medical center between 1999 and 2011, (58 937 deliveries). Women diagnosed with 34DPT following delivery were compared to control group. Multivariate logistic regression analysis and tree classification analysis were used to identify combinations of risk factors which were associated with considerable risk for 34DPT. Results: Overall, 356 (0.6%) deliveries were complicated by 34DPT (340 (95.5%) third-degree tears and 16 (4.5%) fourth-degree tears). Independent predictors of 34DPT were: forceps delivery (odds ratio (OR) = 5.5, confidence interval (CI) 3.9–7.8), precipitate labor (OR = 5.2, CI 2.9–9.2), persistent occiput posterior position (OR = 2.6, CI 1.6–4.3), vacuum extraction (OR = 1.9, CI 1.4–2.6) as well as large for gestational age (LGA) infant and gestational age > 40 weeks. Fourth-degree tears were associated with forceps delivery (OR = 12.5, CI 2.3–66.2), precipitate labor (OR = 9.7, 95%-CI 1.2–75.4) and LGA infant (OR = 7.4, 95%-CI 1.7 –1.5). Overall, the predictability of 34DPT was limited (R2 = 0.4). In subgroups of women with certain combinations of risk factors the risk of 34DPT ranged from 10% to 25%. Conclusion: Despite the limited predictability of 34DPT by individual risk factors, the use of combinations of risk factors may assist obstetricians in identifying women who are at especially high risk for 34DPT.

The role of bariatric surgery in morbidly obese patients with inflammatory bowel disease.

BACKGROUND Bariatric surgery is considered as being contraindicated for morbidly obese patients who also have inflammatory bowel disease (IBD). The aim of our study was to report the outcomes of bariatric surgery in morbidly obese IBD patients. METHODS The prospectively collected data of all the patients diagnosed as having IBD who underwent bariatric operations in 2 medical centers between October 2006 and January 2014 were retrieved and analyzed. RESULTS One male and 9 female morbidly obese IBD patients (8 with Crohns disease and 2 with ulcerative colitis) underwent bariatric surgery. Their mean age was 40 years, and their mean body mass index was 42.6 kg/m2. Nine of them underwent a laparoscopic sleeve gastrectomy and 1 underwent a laparoscopic adjustable gastric band. Eight patients had obesity-related co-morbidities, including type 2 diabetes, hypertension, sleep apnea, osteoarthropathy, etc. After a median follow-up of 46 months (range 9-67), all of the patients lost weight, with an excess weight loss of 71%, and 10 out of 16 obesity-related co-morbidities were resolved. There was 1 complication not related to IBD, and no IBD exacerbation. CONCLUSION Bariatric surgery was safe and effective in our morbidly obese IBD patients. The surgical outcome in this selected patient group was similar to that of comparable non-IBD patients.

Three-dimensional endoanal ultrasonography of external anal sphincter defects in patients with faecal incontinence: correlation with symptoms and manometry.

Aim  Anal sphincter anatomy on two‐dimensional endoanal ‐ultrasonography (EUS) does not always correlate with the clinical data. The purpose of this study was to determine whether three‐dimensional (3D) measurements yield a better correlation.

Perforation and mortality after cleansing enema for acute constipation are not rare but are preventable.

Objectives Constipation is a common complaint, frequently treated with cleansing enema. Enemas can be very effective but may cause serious adverse events, such as perforation or metabolic derangement. Our aim was to evaluate the outcome of the use of cleansing enema for acute constipation and to assess adverse events within 30 days of therapy. Methods We performed a two-phase study: an initial retrospective and descriptive study in 2010, followed by a prospective study after intervention, in 2011. According to the results of the first phase we established guidelines for the treatment of constipation in the Emergency Department and then used these in the second phase. Results There were 269 and 286 cases of severe constipation in the first and second periods of the study, respectively. In the first study period, only Fleet® Enema was used, and in the second, this was changed to Easy Go enema (free of sodium phosphate). There was a 19.2% decrease in the total use of enema, in the second period of the study (P < 0.0001). Adverse events and especially, the perforation rate and the 30-day mortality in patients with constipation decreased significantly in the second phase: 3 (1.4%) versus 0 (P = 0.0001) and 8 (3.9%) versus 2 (0.7%) (P = 0.0001), for perforation and death in the first and second period of the study, respectively. Conclusion Enema for the treatment of acute constipation is not without adverse events, especially in the elderly, and should be applied carefully. Perforation, hyperphosphatemia (after Fleet Enema), and sepsis may cause death in up to 4% of cases. Guidelines for the treatment of acute constipation and for enema administration are urgently needed.