Tumor compartments: A ‘revolution’ in cancer surgery

Medical Tribune July 2009 SFIV
David Brill

A novel approach to treating cervical cancer may signal the end of the radical hysterectomy and could one day revolutionize the field of surgical oncology, says a pioneering team of German surgeons.

By removing only the embryologically defined ‘compartments’ in which tumors are most likely to spread, the surgeons can spare surrounding tissues and minimize collateral damage.

The technique reduces complications and recurrence rates, removes the need for radiotherapy, and could improve survival rates by as much as 20 percent compared to conventional hysterectomy, the group reported recently in The Lancet Oncology.

Research is already underway to extend the concept to vulvar and endometrial cancers, said lead researcher Professor Michael Höckel, chairman of the department of obstetrics and gynecology at the University of Leipzig, Germany.

“We have found that the tumor is confined for a long time in its natural course to a defined tissue compartment – it’s not like an explosion infiltrating all tissues around the tumor,” said Höckel.

“This new perspective in surgical anatomy enables you to see and operate on the tissue in which the tumor is spreading, irrespective of the tumor entity. This is a general principle which could really revolutionize surgical treatment for malignant disease,” he said.

The cervical cancer procedure – total mesometrial resection (TMMR) – targets only the non-distal part of the Müllerian compartment. Surgeons remove the proximal vagina, uterus and extra-cervical mesenchyme but spare nearby non-Müllerian tissues, including the nerves which supply the vagina, bladder and rectum.

Results from 212 women who underwent TMMR without radiotherapy at the University of Leipzig show an overall 5-year survival rate of 96 percent, and recurrence-free survival of 94 percent. The study was conducted prospectively from October 1999 to July 2008 on women with early-stage cancers: International Federation of Gynecology and Obstetrics (FIGO) stages IB, IIA and selected IIB. [Lancet Oncol 2009 May 29; Epub ahead of print]

Sixty two percent of procedures were complication-free at a median of 41 months’ follow-up; 35 percent of patients had grade one complications and 9 percent had grade two. Three patients had developed pelvic cancer recurrence, five developed distant recurrences, and two developed both pelvic and distant recurrence.

Höckel and colleagues developed the principle of TMMR by studying uterovaginal development in embryos and fetuses – enabling discrimination of tissue compartments on the basis of their embryological origin. Previous work showed that early cervical tumors grow largely along these lines. [Lancet Oncol 2005 Oct;6(10):751-6]

Singapore surgeon Adjunct Associate Professor Yam Kwai Lam said that he would be “open to any new technique” as long as it provided “substantial overall benefit to the patient.”

“The published results look impressive, but lacking in long-term survival data. In order for the technique to replace conventional hysterectomies, validation would require a large randomized controlled trial to provide the answer,” said Yam, head and senior consultant in the department of gynecological oncology at KK Women’s and Children’s Hospital.

Höckel has previously presented TMMR to surgeons in Southeast Asia – performing live demonstrations in Hong Kong in December 2006, and Bangkok in August 2008.

A multicenter trial is due to launch soon in Germany, with a view to comparing results of 200 TMMRs against 200 conventional hysterectomies. Publication is expected in around 4 years, said Höckel, who has not performed a standard hysterectomy since first developing TMMR some 10 years ago.

“The conventional techniques have no right to exist any longer because they are wrong. Now that we know how a tumor is spreading … it’s no longer acceptable to use these sub-prime concepts and techniques,” he said.

Simple surgical checklist cuts deaths and complications

Medical Tribune March 2009 P7
David Brill

Using a simple checklist for surgical procedures could dramatically reduce mortality and complication rates across the globe, the “unprecedented” results of a new study show.

Implementation of the WHO-developed list saw post-surgical death rates drop from 1.5 percent to 0.8 percent (P=0.003), and inpatient complications fall from 11 percent to 7 percent (P<0.001)> over 11 months.

The checklist was trialed at hospitals in eight diverse cities, ranging from London to Manila to Ifakara in Tanzania. Data were collected from 3,733 procedures conducted before implementation of the list, and 3,955 after. [N Engl J Med 2009 Jan 29;360(5):491-9]

“The concept of using a brief but comprehensive checklist is surprisingly new to us in surgery. Not everyone on the operating teams was happy to try it,” said Dr. Atul Gawande, senior author of the study. “But the results were unprecedented. And the teams became strong supporters.

“These findings have implications beyond surgery, suggesting that checklists could increase the safety and reliability of care in numerous medical fields. The checklists must be short, extremely simple, and carefully tested in the real world. But in specialties ranging from cardiac care to pediatric care, they could become as essential in daily medicine as the stethoscope,” added Gawande, an associate professor of surgery at Harvard Medical School, US, and team leader for the WHO project.

The checklist was first launched in 2008 as part of new “safe surgery” guidelines from the WHO. It comprises 19 items, and is used at three “critical junctures” in care: before anesthesia, before incision, and before the patient is taken from the operating room.

Rates of surgical site infection also dropped following implementation of the list – from 6.2 to 3.4 percent (P<0.001)> – and unplanned reoperation rates decreased from 2.4 to 1.8 percent (P=0.047).

Dr. Sophia Ang, patient safety officer and associate chairman of the medical board at National University Hospital (NUH), Singapore, said that similar checklists are already in use at NUH.

“Some of these have been in place for a long time, such as an instrument count, sponge count and needle count,” she said.

“There is no deliberate effort on our part to do this as a scientific research so we have no findings to conclusively show that the changes have brought about improved outcomes. Some of the elements were introduced in phases and over time and we are continually reviewing and improving on them to enable us to meet our patient safety needs,” she added.

Some 234 million operations are performed worldwide each year, according to Gawande and his colleagues. At least half of all complications arising from surgery are thought to be avoidable, they add.

The study, which was conducted between October 2007 and September 2008, included only patients aged over 16 who underwent noncardiac surgery. The other cities where the checklist was tested were New Delhi, India; Toronto, Canada; Amman, Jordan; Auckland, New Zealand; and Seattle, US.

Chewing gum speeds recovery from bowel cancer op

Medical Tribune October 2008 P3

Chewing gum could help patients to recover after colectomy, a recent meta-analysis has shown.

The study, including five randomized controlled trials totaling 158 patients, found that gum significantly reduced the time to first flatus and first bowel movement following the operation. Postoperative hospital stay was also reduced, but this result did not reach statistical significance.

The researchers, from Imperial College London, UK, suggest that gum could serve as a form of “sham feeding” which stimulates the production of saliva, gastrointestinal hormones and pancreatic secretions.The potential for substantial cost savings means that larger placebocontrolled trials into the effects of chewing gum are warranted, they conclude. [Arch Surg 2008 143(8):788-93]

Second-ever face transplant hailed as a success

Medical Tribune October 2008 P9
David Brill

Two years after the world’s second face transplant, the operation seems to have been a success.

Despite some complications, including three episodes of acute rejection, the patient is now healthy, able to eat, drink and talk as normal and has accepted his new face, the Chinese surgical team reported in The Lancet. [2008 Aug 23;372:631-8]

The tissue graft survived well, regaining normal skin temperature, texture and color, and did not become infected at any point.

Professor Shuzhong Guo and colleagues from the Fourth Military Medical University in Xi’an, Shaanxi Province, China, performed the procedure in April 2006. The recipient is a 30-year-old man from Yunnan Province whose face was badly disfigured by a bear in October 2004.

The graft, which was taken from a 25-year old male who had died in a road traffic accident, comprised the top lip, the whole nose, the intact parotid gland, zygomatic bone, the front wall of the maxillary sinus, and a section of the infraorbital wall.

The patient experienced an acute rejection episode three months after surgery and again at five and 17 months. These episodes involved reddening of the skin, swelling and inflammation, but were all successfully controlled with various regimens of tacrolimus, methylprednisolone and prednisone.

Hyperglycemia developed after three days but was controlled with insulin therapy. Renal, hepatic and gastrointestinal function were not adversely affected by the procedure.

“This case suggests that facial transplantation might be an option for restoring a severely disfigured face, and could enable patients to readily reintegrate themselves back into society,” the doctors wrote in the study.

The first-ever partial facial transplant was performed in November 2005 by a team of surgeons led by Professor Bernard Devauchelle from the Centre Hospitalier Universitaire Amiens, France. The recipient was a 38-year-old woman whose face had been bitten by her dog. [Lancet
2006;368:203-9]

The Chinese case differed in that the graft included bone as well as skin, and was taken following cardiac death rather than brain death.

A third transplant was carried out in January 2007 by another French team, which reported their 1-year follow-up in the same journal issue as the Chinese case. [Lancet 2008 Aug 23;372:639-45] The recipient was a 29-year-old man who had a massive plexiform neurofibroma affecting the middle and lower part of his face. He experienced two rejection episodes but has otherwise made a good functional and psychological recovery, the doctors reported, lending further support to the viability of the procedure.