Role of prophylactic surgery in spinal tuberculosis: A retrospective study from Eastern India

Background

Tuberculosis (TB) is broadly classified into pulmonary and extrapulmonary TB. Skeletal TB is considered to be a form of extrapulmonary TB whose incidence is around 1% of all forms of TB. The incidence of spinal TB is more than 50% of the entire skeletal TB.

Methods

A total of 92 consecutive patients, treated over a period of 2 years (January 2021-January 2023), are retrospectively analyzed.

Results

In our study, out of 92 patients, the pain had subsided in 90% of cases, and 12 patients showed improvement in motor power postoperatively. In our study, the patients have benefited due to the surgical intervention in decrease of pain and improvement in motor deficits in patients. The 29 patients who were operated on prophylaxis with pain as the only symptom benefitted from the resolution of the symptom of pain and did not develop any morbidity in their long-term follow-up. The sensory and bladder/bowel symptoms did not improve after surgery.

Conclusions

In the author's view, prophylactic surgery for spinal TB is safe and effective with confirmation of the disease. However, a well-designed randomized controlled trial, to definitely and objectively prove the usefulness of prophylactic surgery, is needed.

Adherence to risk-reducing salpingo-oophorectomy guidelines among gynecologic oncologists compared to general gynecologists

BACKGROUND

Risk-reducing bilateral salpingo-oophorectomy reduces mortality from high-grade serous carcinoma in patients with hereditary breast and ovarian cancer associated gene mutations. Ideal surgical management includes 5 steps outlined in 2005 by the Society of Gynecologic Oncology and the American College of Obstetricians and Gynecologists. In addition, it is recommended that pathologic examination include serial sectioning of specimens. In practice, risk-reducing salpingo-oophorectomy is performed by both gynecologic oncologists and general gynecologists. To ensure optimal detection of occult malignancy, standardized adherence to outlined guidelines is necessary.

OBJECTIVE

This study aimed to evaluate the adherence to optimal surgical and pathologic examination guidelines and to compare the rate of occult malignancy at the time of surgery between 2 provider types.

STUDY DESIGN

Institutional review board exemption was obtained. A retrospective review of patients undergoing risk-reducing bilateral salpingo-oophorectomy without hysterectomy from October 1, 2015, to December 31, 2020, at 3 sites within a healthcare system was conducted. The inclusion criteria included age ≥18 years and a documented indication for surgery being a mutation in BRCA1 or BRCA2 or a strong family history of breast and/or ovarian cancer. Compliance with 5 surgical steps and pathologic specimen preparation was based on medical record documentation. Multivariable logistic regression was used to determine differences in adherence between provider groups and surgical and pathologic examination guidelines. A P value of <.025 was considered statistically significant for the 2 primary outcomes after Bonferroni correction was applied to adjust for multiple comparisons.

RESULTS

A total of 185 patients were included. Among the 96 cases performed by gynecologic oncologists, 69 (72%) performed all 5 steps of surgery, 22 (23%) performed 4 steps, 5 (5%) performed 3 steps, and none performed 1 or 2 steps. Among the 89 cases performed by general gynecologists, 4 (5%) performed all 5 steps, 33 (37%) performed 4 steps, 38 (43%) performed 3 steps, 13 (15%) performed 2 steps, and 1 (1%) performed 1 step. Gynecologic oncologists were more likely to document adherence to all 5 recommended surgical steps in their surgical dictation (odds ratio, 54.3; 95% confidence interval, 18.1-162.7; P<.0001). Among the 96 cases documented by gynecologic oncologists, 41 (43%) had serial sectioning of all specimens performed, compared with 23 of 89 cases (26%) performed by general gynecologists. No difference in adherence to pathologic guidelines was identified between the 2 provider groups (P=.0489; note: P value of >.025). Overall, 5 patients (2.70%) had occult malignancy diagnosed at the time of risk-reducing surgery, with all surgeries performed by general gynecologists.

CONCLUSION

Our results demonstrated greater compliance with surgical guidelines for risk-reducing bilateral salpingo-oophorectomy in gynecologic oncologists than in general gynecologists. No considerable difference was determined between the 2 provider types in adherence to pathologic guidelines. Our findings demonstrated a need for institution-wide protocol education and implementation of standardized nomenclature to ensure provider adherence to evidence-based guidelines.

Unique challenges of risk-reducing surgery for hereditary diffuse gastric cancer syndrome: a narrative review

The common use of genetic testing has reinvigorated discussions surrounding enhanced cancer surveillance, chemoprevention, and preventive surgery strategies due to increasing recognition of pathogenic germline genetic variants. Prophylactic surgery for hereditary cancer syndromes can significantly reduce the risk of developing cancer. Hereditary diffuse gastric cancer (HDGC), characterized by high penetrance and an autosomal dominant inheritance pattern, is causally linked to germline mutations in the CDH1 tumor suppressor gene. Risk-reducing total gastrectomy is currently recommended in patients with pathogenic and likely pathogenic CDH1 variants; however, the physical and psychosocial sequelae of complete stomach removal are substantial and need to be investigated further. In this review, we address the risks and benefits of prophylactic total gastrectomy for HDGC in the context of prophylactic surgery for other highly penetrant cancer syndromes.

Fate of the distal aorta following root replacement in Marfan syndrome: a propensity score matched study

Objective

The aortic root is the most frequent segment involved in Marfan syndrome. However, Marfan syndrome is a systemic hereditary connective tissue disorder, and knowledge regarding the outcomes of the native distal aorta after prophylactic aortic root surgery is limited.

Methods

From April 2010 to December 2020, 226 patients with Marfan syndrome and 1,200 patients without Marfan syndrome who underwent Bentall procedures were included in this study. By propensity score matching, 134 patients were assigned to each group. Clinical manifestations and follow-up data were acquired from hospital records and telephone contact. The cumulative incidence of aortic events was estimated in Marfan and non-Marfan patients with death as a competing risk.

Results

Patients with and without Marfan syndrome had similar baseline characteristics after propensity score matching. Differences in the aortic root (62.25 ± 11.96 vs. 54.03 ± 13.76, P < .001) and ascending aorta (37.71 ± 9.86 vs. 48.16 ± 16.01, P < .001) remained after matching. No difference was observed in the frequency of aortic adverse events between the two groups (10.5% vs. 4.6%, P = 0.106). The cumulative incidence of aortic events was not different between Marfan and non-Marfan patients (15.03% ± 4.72% vs. 4.18% ± 2.06%, P = 0.147). Multivariate Cox regression indicated no significant impact of Marfan syndrome on distal aortic events (HR: 1.172, 95% CI: 0.263-5.230, P = 0.835). Descending and abdominal aortic diameter above normal at the initial procedure were associated with the risk of distal aortic events (HR: 20.735, P = .003, HR: 22.981, P = .002, respectively).

Conclusions

New-onset events of the residual aorta in patients undergoing Bentall procedures between the Marfan and non-Marfan groups were not significantly different. Distal aortic diameter above normal at initial surgery was associated with a higher risk of adverse aortic events.

Prophylactic Surgery for Thoracic Aortic Aneurysm: Asking Family for Help

A 68-year-old man presented for evaluation of a 5.0-cm asymptomatic ascending aortic aneurysm. He was managed medically until a family member was also diagnosed with a thoracic aortic aneurysm. His aneurysm was, therefore, likely to be genetically predisposed, and he underwent early prophylactic ascending aorta replacement. (Level of Difficulty: Beginner.).

Impact of valve repair on mild tricuspid insufficiency in rheumatic mitral surgery

OBJECTIVE

Tricuspid valve repair for mild tricuspid regurgitation during rheumatic mitral valve surgery is controversial. We evaluated the benefit of tricuspid valve repair for mild tricuspid regurgitation in rheumatic mitral valve surgery.

METHODS

Among 1208 consecutive patients (52.6 ± 11.9 years) with mild tricuspid regurgitation who underwent rheumatic mitral valve surgery from 2000 to 2018 in 2 referral centers, 419 received concomitant tricuspid valve repair and 789 did not. The primary end point was the development of severe tricuspid regurgitation. Deaths were regarded as competing events. Secondary end points were death and heart failure. Inverse probability of treatment weighting was performed to reduce selection bias. Multivariable competing risk analysis was performed to determine the predictive factors of severe tricuspid regurgitation.

RESULTS

There was no significant difference in early mortality rates between patients with and without tricuspid valve repair (P = .26). During a median follow-up of 71.6 (interquartile range: 25.3-124.2) months, the primary end point was detected in 7 of 419 patients (0.25%/patient-years) and 28 of 789 patients (0.57%/patient-years) with and without tricuspid valve repair, respectively (P = .04). There were no significant differences in the secondary end points. After baseline adjustment, the primary end point was not significantly different depending on the addition of tricuspid valve repair (hazard ratio, 0.64; 95% confidence interval, 0.23-1.77; P = .39). In multivariable analysis, only the omission of surgical atrial fibrillation ablation (hazard ratio, 4.52; 95% confidence interval, 2.07-9.87) was significantly associated with the development of severe tricuspid regurgitation.

CONCLUSIONS

Tricuspid valve repair for mild tricuspid regurgitation in rheumatic mitral valve surgery provides no overt clinical benefit.

Risk-reducing surgery in unaffected individuals receiving cancer genetic testing in an integrated health care system

BACKGROUND

Germline genetic testing enables primary cancer prevention, including through prophylactic surgery. We examined risk-reducing surgeries in unaffected individuals tested for hereditary cancer susceptibly between 2010 and 2018 in the Kaiser Permanente Northwest health system.

METHODS

We used an internal genetic testing database to create a cohort of individuals who received tests including one or more high-penetrance hereditary cancer susceptibility gene. We then identified, after testing, bilateral mastectomy, bilateral salpingo-oophorectomy (BSO), and total hysterectomy procedures in electronic health record and claims data through 2019. We describe surgery utilization by genetic test results and National Comprehensive Cancer Network (NCCN) guidelines.

RESULTS

The cohort included 1020 individuals, 16% with pathogenic/likely pathogenic (P/LP) variants in one or more of the following genes: BRCA1, BRCA2, CHEK2, APC, MUTYH, ATM, MSH2, PALB2, BRIP1, MLH1, MSH6, EPCAM, FLCN, RAD51C, RAD51D, or TP53. Among individuals with P/LP variants making them candidates for mastectomy, BSO, or hysterectomy per NCCN guidelines, 34% (33/97), 24% (23/94), and 8% (1/12), respectively, underwent surgery during follow-up. Fifty-three percent (18/37) of hysterectomies were among APC, BRCA1, and BRCA2 P/LP variant heterozygotes, typically concurrent with BSO. Three individuals with variants of uncertain significance (only) and 22 with negative results had prophylactic surgery after genetic testing.

CONCLUSIONS

Uptake of risk-reducing surgery following usual care genetic testing appears to be lower than in studies that actively recruit high-risk patients and provide testing and follow-up care in specialized settings. Factors in addition to genetic test results and NCCN guidelines motivate prophylactic surgery use and deserve further study.

Impact of Tumor Growth Speed of Primary Lesions on the Clinical Outcomes of Appendicular Skeletal Metastases

BACKGROUND/AIM

This study aimed to investigate the clinical influence of the growth speed of primary lesions on appendicular skeletal metastases to provide an optimal treatment strategy for the metastases.

PATIENTS AND METHODS

Fifty-seven patients who underwent surgery for appendicular skeletal metastases between 2008 and 2020 were included. According to the growth speed of primary lesions, the patients were divided into the S group (slow-to-moderate, n=34) and the R group (rapid, n=23), and the outcomes were investigated.

RESULTS

The period from diagnosis of skeletal metastases to pathological fracture (PF) was shorter in the R group than in the S group (p=0.24). The overall survival of the S group was significantly better than that of the R group (p=0.02).

CONCLUSION

The appendicular skeletal metastases of the primary tumor with rapid growth speed have a high risk of PFs developed early from the diagnosis of skeletal metastases, and the prognosis may be poor.

Breast cancer characteristics and surgery among women with Li-Fraumeni syndrome in Germany-A retrospective cohort study

Background

Women with Li‐Fraumeni syndrome (LFS) have elevated breast cancer (BC) risk. Optimal BC treatment strategies in this population are yet unknown.

Methods

BC subtypes and treatment were retrospectively investigated between December 2016 and January 2019 in a multicentre study. BC risks were evaluated according to the type of surgery.

Results

Thirty‐five women of our study population (35/44; 79.5%) had developed 36 breast lesions at first diagnosis at a mean age of 34 years. Those breast lesions comprised 32 invasive BCs (89%), three ductal carcinoma in situ alone (8%) and one malignant phyllodes tumour (3%). BCs were mainly high‐grade (18/32), of no special type (NST; 31/32), HER2‐enriched (11/32) or luminal‐B‐(like)‐type (10/32). Affected women (n = 35) received breast‐conserving surgery (BCS, n = 17) or a mastectomy (ME, n = 18) including seven women with simultaneous contralateral prophylactic mastectomy (CPM) at first diagnosis. Nineteen women suffered 20 breast or locoregional axillary lesions at second diagnosis with mean age of 36. Median time between first and second diagnosis was 57 months; median time to contra‐ and ipsilateral recurrence depended on surgical strategies (BCS: 46 vs. unilateral ME: 93 vs. bilateral ME > 140 months). Women with a primary treatment of solitaire therapeutic ME suffered from contralateral BC earlier compared to those with therapeutic ME and CPM (median: 93 vs. >140 months).

Conclusion

Aggressive BC subtypes occur among women with LFS. Surgical treatment, i.e. ME and CPM, may prolong time to a second BC diagnosis. Conclusion on long‐term survival benefit is pending. Individual competing tumour risks and long‐term outcomes need to be taken into consideration.

Prophylactic Surgery in the BRCA+ Patient: Do Women Develop Breast Cancer While Waiting?

Breast cancer susceptibility gene (BRCA) mutation carriers have an increased risk of breast cancer. Mitigation of this risk can be achieved via surveillance or prophylactic mastectomy with or without breast reconstruction. Those that choose surgery expect to reduce their chance of developing cancer. The purpose of this study was to determine the incidence of patients developing breast cancer prior to surgery and to identify modifiable contributing factors within the patient journey. This is a historical cohort study of all BRCA mutation carriers identified through the British Columbia Cancer Hereditary Cancer Program between 2000 and 2012. Patients were divided into two groups: surveillance (S) and prophylactic mastectomy with immediate breast reconstruction (PM/IBR). The incidence of cancer, time to PM/IBR and patient journeys were analyzed. A total of 333 women were identified. The time to surgery from mutation disclosure was a median of 31 (5.3, 75.7) months. During this period, 6% of patients developed breast cancer compared with a 14% incidence of breast cancer in patients choosing surveillance. The majority of time to surgery was attributed to the period between mutation disclosure and the decision to proceed with surgery. Strategies to facilitate decision-making as well as wait list prioritization and dedicated operative time should be targeted to this population to decrease the number of women developing an interval cancer prior to surgery.

Probabilistic Risk Assessment of Prophylactic Surgery Before Extended-Duration Spaceflight

Introduction. Prophylactic surgery before spaceflight may eliminate the risk of appendicitis and cholecystitis in astronauts on deep space missions. However, even minimally invasive surgery increases the risk of small bowel obstruction (SBO). Probabilistic risk assessment (PRA) is a method that can be used to estimate the benefits and risks of prophylactic surgery. Methods. Risks of appendicitis and cholecystitis during a 2.5-year Mars mission are compared to the risk of SBO after laparoscopic removal of the appendix, gallbladder, or both. A PRA model using Monte Carlo methodology was used to forecast the risks. Results. Prophylactic appendectomy and cholecystectomy combined, conferred an increased probability of medical evacuation (pEVAC) due to SBO as compared to the no surgery group. A slightly higher probability for the loss of crew life (pLOCL) was found in the no surgery group when compared to the cases in which either prophylactic appendectomy alone, or appendectomy plus cholecystectomy are performed. Discussion. The need for medical evacuation can be viewed as a potential risk for death in the context of a space mission where evacuation is not possible. Because of the higher pEVAC due to SBO and relatively small benefit in the reduction of pLOCL in the prophylactic surgery groups, this analysis does not support the prophylactic removal of appendix and/or gallbladder for spaceflight. Future advances in surgical or medical technique or mission medical capabilities may change these results. This work demonstrates the utility of PRA in providing quantitative answers to "what if" questions where limited information is available.

Personalised external aortic root support (PEARS) to stabilise an aortic root aneurysm

Patients with congenitally determined aortic root aneurysms are at risk of aortic valve regurgitation, aortic dissection, rupture and death. Personalised external aortic root support (PEARS) may provide an alternative to aortic root replacement. This was a multi-centre, prospective cohort of all consecutive patients who received ExoVasc mesh implants for a dilated aortic root between 2004 and 2017. Baseline and peri-operative characteristics, as well as early postoperative outcomes are described, and time-related survival and re-operation free survival are estimated using the Kaplan-Meier method. From 2004 through 2017, 117 consecutive patients have received ExoVasc mesh implants for aortic root aneurysm. The inclusion criteria were an aortic root/sinus of Valsalva and ascending aorta with asymptomatic dilatation of between 40 and 50 mm in diameter in patients aged 16 years or more. Patients with more than mild aortic regurgitation were excluded. There was one early death. The length of stay was within seven days in 75% of patients. In conclusion, the operation achieves the objectives of valve-sparing root replacement. PEARS may be seen as a low-risk conservative operation, which can be applied earlier on in the disease process, and which is complementary to more invasive procedures, such as valve-sparing root replacement or total root replacement.

Hereditary Gastric and Breast Cancer Syndromes Related to CDH1 Germline Mutation: A Multidisciplinary Clinical Review

E-cadherin (CDH1 gene) germline mutations are associated with the development of diffuse gastric cancer in the context of the so-called hereditary diffuse gastric syndrome, and with an inherited predisposition of lobular breast carcinoma. In 2019, the international gastric cancer linkage consortium revised the clinical criteria and established guidelines for the genetic screening of CDH1 germline syndromes. Nevertheless, the introduction of multigene panel testing in clinical practice has led to an increased identification of E-cadherin mutations in individuals without a positive family history of gastric or breast cancers. This observation motivated us to review and present a novel multidisciplinary clinical approach (nutritional, surgical, and image screening) for single subjects who present germline CDH1 mutations but do not fulfil the classic clinical criteria, namely those identified as-(1) incidental finding and (2) individuals with lobular breast cancer without family history of gastric cancer (GC).

Non-surgical prevention strategies in women with hereditary breast and ovarian cancer syndromes

Objectives To review non-surgical prevention strategies in women with hereditary breast and ovarian cancer syndromes. Content Women with a gBRCA1 or 2 mutations face a high cumulative breast and ovarian cancer risk. While bilateral mastectomy (PBM) and bilateral salpingo-oophrectomy (PBSO) profoundly reduce the respective cancer risks, they are also associated with considerable side effects. There is therefore an urgent need for alternative and non-surgical risk reduction options. Tamoxifen and aromatase inhibitors have both been evaluated in secondary prevention, but their benefit in primary prevention is currently unknown in BRCA mutation carriers. In addition, their use is compromised by their side effect profile which makes them less appealing for a use in chemoprevention. Summary and outlook Denosumab is a well-tolerated osteoprotective drug, which has been demonstrated to have a potential preventive effect particularly in BRCA1-deficient models in vitro. The prospectively randomized double-blind BRCA-P trial is currently investigating the preventative effect of denosumab in healthy BRCA1 germ line mutation carriers.

The Effect of Percutaneous Flexor Tenotomy on Healing and Prevention of Foot Ulcers in Patients With Claw Deformity of the Toe

Claw deformity of the foot is frequently seen in patients with diabetes mellitus. Percutaneous flexor tenotomy is a simple surgical procedure for the treatment of foot ulcers on the distal end of the toe caused by this deformity. This procedure can also be performed to prevent ulcers in claw toes that are at risk of ulceration. The aim of this study is to investigate whether percutaneous flexor tenotomy is an effective surgical method for treatment and prevention of toe ulcers in patients with claw deformity. This retrospective study, with a median follow-up of 13.4 (1 to 66.7) months, included all consecutive patients who underwent percutaneous flexor tenotomy in 2 hospitals between July 2012 and April 2017. In total, 101 feet underwent flexor tenotomy: 84 (83.3%) therapeutic and 17 (16.7%) prophylactic. Of the 84 therapeutic procedures, 95.1% healed, with a median healing time of 27 days. In 11 (13.3%) therapeutic procedures, a reulceration was recorded. In the therapeutic group, 4 (4.8%) infections and 1 (1.2%) amputation of the digit occurred. In the 17 prophylactic procedures, local bleeding was recorded in 1 (5.9%). In the prophylactic group, 2 ulcers occurred. In 77 (76.2%) of all procedures, patients had diabetes mellitus. In conclusion, percutaneous flexor tenotomy is an effective, safe, and minimally invasive procedure for the treatment and prevention of toe ulcers in patients with claw deformity.

Meckel's diverticulum in the adult: surgical treatment

Introduction: Management of asymptomatic Meckel's diverticulum (MD) incidentally discovered in adults remains controversial. The aim of this study was to determine if incidental diverticula should be removed. Materials and methods: We reviewed a consecutive series of patients surgically managed from January 1994 to December 2016. Patients were divided into two groups according to symptomatic or asymptomatic diverticula, and characteristics were compared. Results: The study included 66 patients: 30 in the symptomatic group (45%) and 36 in the incidental group (55%). We found 12 females (18.2%), and the ratio male:female was higher in the symptomatic group (14:1 vs. 2.6:1). Patients in the symptomatic group were significantly younger: 41.7 ± 18.1 vs. 54.7 ± 19.8 years (p = .007). MD in the symptomatic group tended to be longer (3.8 ± 1.9 vs. 2.6 ± 0.9 cm; p = .003). A MD-associated malignancy was present in three patients (4.5%), all neuroendocrine tumours. Major postoperative complications occurred in 6.6% of symptomatic patients and 0% within the incidental group, without specific morbidity related to prophylactic surgery. No mortality was observed. Conclusion: Resection of incidentally found Meckel's diverticulum can be made because of benefits outweigh the risks in this high-risk area for cancer.

Management of Gynecologic Cancers In Relation to Genetic Predisposition

OBJECTIVE

To review hereditary gynecologic cancer syndromes and outline current clinical management considerations.

DATA SOURCES

Retrieved articles and guidelines dated 2013-2018 from PubMed, National Comprehensive Cancer Network, American College of Medical Genetics and Genomics, American College of Obstetricians and Gynecologists, American Cancer Society, National Cancer Institute, Centers for Disease Control and Prevention, and National Institutes of Health databases.

CONCLUSION

Advances in genetic testing technology have allowed for the identification of a growing number of patients with genetic mutations associated with hereditary cancer. Individuals with a hereditary predisposition to cancer may qualify for targeted drug therapies, risk-reducing surgeries, and/or high-risk cancer surveillance depending on the specific gene mutation(s) they harbor. Furthermore, there are clinical implications for relatives.

IMPLICATIONS FOR NURSING PRACTICE

This article is an educational guide for oncology nurses who often play a key role in identifying patients at risk for hereditary cancer, prompting referrals for genetic evaluation, and providing follow-up care for these patients.

Microsurgical efficacy in 326 children with tethered cord syndrome: a retrospective analysis

Tethered cord syndrome is a progressive disease with a typically insidious onset in infants and children, and which can lead to persistent progress of neurological deficits and a high rate of disability without timely intervention. The purpose of this study was to investigate the curative effect of microsurgery in children with different types of tethered cord syndrome. In this study, we analyzed 326 patients with tethered cord syndrome, aged from 2 months to 14 years old, who were followed for 3-36 months after microscopic surgery. Based on clinical manifestations and imaging findings, these patients were classified into five types: tight filum terminale (53 cases), lipomyelomeningocele (55 cases), lipomatous malformation (124 cases), postoperative adhesions (56 cases), and split cord malformation (38 cases). All patients underwent microsurgery. Curative effects were measured before and 3 months after surgery by Spina Bifida Neurological Scale based on sensory and motor functions, reflexes, and bladder and bowel function. The results showed that Spina Bifida Neurological Scale scores improved in all five types after surgery. Overall effective rates in these patients were 75%. Effective rates were 91% in tight filum terminale, 84% in lipomyelomeningocele, 65% in lipomatous malformation, 75% in postoperative adhesion, and 79% in split cord malformation. Binary logistic regression analysis revealed that types of tethered cord syndrome (lipoma-type or not) and symptom duration before surgery were independent influencing factors of surgical outcome. These results show that therapeutic effect is markedly different in patients with different types of tethered cord syndrome. Suitable clinical classification for tethered cord syndrome will be helpful in predicting prognosis and guiding treatment. This trial has been registered in the Chinese Clinical Trial Registry (registration number: ChiCTR1800016464).

Comprehensive clinical genetics care for patients with inherited colorectal cancer associated with Lynch syndrome: Western and Asian perspectives

Lynch syndrome (LS) arises from germline mutations that lead to defective functioning of the DNA mismatch repair (MMR) system. It is the most common cause of inherited colorectal cancer (CRC), and predisposes individuals to significantly elevated risks for extracolonic cancers. A sensitive and accurate diagnostic approach will enable proactive management of the proband and at-risk relatives in order to minimize their cancer burden. Comprehensive clinical genetics care should include personalized and tailored multidisciplinary oncologic care, with consideration for the extent of surgical resection, the choice of systemic agents, and the use of radiation. Preventive strategies including lifelong multi-organ surveillance, testing of family members, prophylactic-intent surgery and chemoprevention should be considered. In this review, we aim to provide an update on the diagnostic approach to LS, and to summarize key components of comprehensive clinical genetics care, through an examination of existing data and guidelines from Asian and from Western perspectives.

Multimodal Treatment of Bone Metastasis-A Surgical Perspective

Over the past decades there has been an increase in the incidence of cancer worldwide. With the advancement in treatment, patient survival has improved in tandem with the increasing incidence. This, together with the availability of advanced modern diagnostic modalities, has resulted in more cases of metastatic bone disease being identified. Bone metastasis is an ongoing problem and has significant morbidity implications for patients affected. Multimodal treatment strategies are required in dealing with metastatic bone disease, which include both surgical and non-surgical treatment options. In the multidisciplinary team, orthopedic surgeons play an important role in improving the quality of life of cancer patients. Surgical intervention in this setting is aimed at pain relief, restoration of function and improvement in functional independence. In selected cases with resectable solitary metastasis, surgical treatment may be curative. With the advancement of surgical technique and improvement in implant design and manufacture, a vast array of surgical options are available in the modern orthopedic arena. In the majority of cases, limb salvage procedures have become the standard of care in the treatment of metastatic bone disease. Non-surgical adjuvant treatment also contributes significantly to the improvement of cancer patient care. A multidisciplinary approach in this setting is of paramount importance.

Successful management of unresectable small bowel lymphoma with laparoscopy-assisted surgical exclusion of the affected intestine

The incidence of small bowel lymphoma (SBL) is increasing worldwide. In contrast to resectable SBL, the treatment of unresectable SBL is still contentious. Here, we report a case of unresectable SBL that was treated by laparoscopic exclusion of the affected intestine before systemic chemotherapy was administered. An 84-year-old man was diagnosed with primary SBL involving extranodal dissemination. The patient received prophylactic surgery, namely exclusion of the affected intestine. This therapy diminishes well-known and life-threatening complications, such as perforation, bleeding, and obstruction, which may still occur after chemotherapy, and it makes the administration of chemotherapy safer. In addition, the surgery provides easy access for direct endoscopic observation and biopsy, which are otherwise difficult to perform. Follow-up after two courses of chemotherapy showed that the patient had achieved complete remission. In conclusion, the procedure described here may be an effective strategy for unresectable SBL.

The Role of Central Neck Lymph Node Dissection in the Management of Papillary Thyroid Cancer

Papillary thyroid cancer (PTC) is the most common thyroid malignancy, and cervical nodal metastases are frequent at presentation. The most common site for nodal metastases from PTC is the central compartment of the ipsilateral neck in the paratracheal and pretracheal regions. The decision to resect these lymph nodes at the time of thyroidectomy often depends on if nodes with suspected malignancy can be identified preoperatively. If nodal spread to the central neck nodes is known, then the consensus is to remove all nodes in this area. However, there remains significant controversy regarding the utility of removing central neck lymph nodes for prophylactic reasons. Herein, we review the potential utility of central neck lymph node dissection as well as the risks of performing this procedure. As well, we review the potential of molecular testing to stratify patients who would most benefit from this procedure. We advocate a selective approach in which patients undergo clinical neck examination coupled with ultrasound to detect any concerning lymph nodes that warrant additional evaluation with either fine needle aspiration or excisional biopsy in the operating room. In lieu of clinical lymphadenopathy, we suggest the use of patient and disease characteristics as identified by multiple groups, such as the American Thyroid Association and European Society of Endocrine Surgeons, which include extremes of ages, large primary tumor size, and male gender, when deciding to perform central neck lymph node dissection. Patients should be educated on the potential long-terms risks versus the lack of known long-term benefits.

Do breast cancer survivors benefit from prophylactic removal of uterus and ovaries? A population-based data linkage replication study

AIM

Our previous population-based research found prophylactic surgery (hysterectomy and bilateral salpingo-oophorectomy [BSO]) halved the mortality risk for premenopausal breast cancer patients. Here we aim to replicate findings in a Western Australia dataset.

METHOD

Data from the Western Australia Cancer Registry of 15 395 women 20-79 years diagnosed with primary breast cancer (1997-2011) was categorized into four groups: neither hysterectomy nor BSO, hysterectomy only, BSO only, or hysterectomy + BSO. We fitted flexible parametric breast cancer-specific and overall survival models with 95% confidence intervals (also known as Royston-Parmar models) to assess the impact of prophylactic surgery.

RESULTS

A total of 12 630 (82.0%) patients had no surgery, 1799 (11.7%) had a hysterectomy only, 337 (2.2%) had BSO only and 629 (4.1%) had both a hysterectomy and BSO. For all-causes mortality, unadjusted 10-year survival was highest for women who had either a hysterectomy + BSO (84.7%) or a hysterectomy only (84.2%). After adjusting for covariates, the survival advantage compared to women without any surgery remained significant for the hysterectomy only group (hazard ratio [HR] = 0.89; 95% confidence interval [CI], 0.81-0.98; P = 0.02). A similar pattern emerged in breast cancer-specific survival with significantly improved survival for women who had a hysterectomy only (HR = 0.83; 95% CI, 0.74-0.94; P = 0.003). However, for non-breast cancer-related survival, having a BSO alone increased risk of death (HR = 1.83; 95% CI, 1.14-2.93; P = 0.01).

CONCLUSION

We observed significantly improved overall and breast cancer-specific survival among women who had a hysterectomy only, but increased non-breast cancer-related risk after BSO only. Breast cancer patients must weigh up pros and cons of prophylactic surgery.

The Angelina Jolie Effect in Jewish Law: Prophylactic Mastectomy and Oophorectomy in BRCA Carriers

BACKGROUND

Following the announcement of actress Angelina Jolie's prophylactic bilateral mastectomies and subsequent prophylactic oophorectomy, there has been a dramatic increase in interest in BRCA testing and prophylactic surgery.

OBJECTIVE

To review current medical literature on the benefits of prophylactic mastectomy and oophorectomy among BRCA-positive women and its permissibility under Jewish law.

RESULTS

Recent literature suggests that in BRCA-positive women who undergo prophylactic oophorectomy the risk of dying of breast cancer is reduced by 90%, the risk of dying of ovarian cancer is reduced by 95%, and the risk of dying of any cause is reduced by 77%. The risk of breast cancer is further reduced by prophylactic mastectomy. Prophylactic oophorectomy and prophylactic mastectomy pose several challenges within Jewish law that call into question the permissibility of surgery, including mutilation of a healthy organ, termination of fertility, self-wounding, and castration. A growing number of Jewish legal scholars have found grounds to permit prophylactic surgery among BRCA carriers, with some even obligating prophylactic mastectomy and oophorectomy.

CONCLUSION

Current data suggest a significant reduction in mortality from prophylactic mastectomy and oophorectomy in BRCA carriers. While mutilation of healthy organs is intrinsically forbidden in Jewish law, the ability to preserve human life may contravene and even mandate prophylactic surgery.

Segmental vs extended colectomy in the management of hereditary nonpolyposis colorectal cancer: a systematic review and meta-analysis

AIM

The optimal surgical approach to the management of colorectal cancer in the setting of hereditary nonpolyposis colorectal cancer (HNPCC) is contentious. While some advocate total colectomy, others perform segmental resection followed by regular endoscopic surveillance. This systematic review evaluates the evidence for segmental colectomy (SC) and total (extended) colectomy (TC) in the management of HNPCC.

METHOD

Two major databases (PubMed and Cochrane) were searched using predefined terms. All original articles, published in English, comparing the oncological outcomes of SC and TC in HNPCC patients from January 1950 to July 2013 were included.

RESULTS

Eighty-four studies were identified. After applying exclusion criteria, six studies involving 948 patients were included (mean age 47.4 years, 51.8% male). SC was more commonly performed than TC (n = 780; 82.3%). Mean follow-up was 106.5 months. Metachronous high-risk adenomas were detected more often after SC, although the difference was not statistically significant (23.4% vs 9.6%; OR 2.258, P = 0.057). Metachronous cancers occurred more frequently after SC than after TC (23.5% vs 6.8%; OR 3.679, P < 0.005). However, there was no difference in overall survival (90.7% vs 89.8% for SC and TC, respectively; P = 0.085). Only one study reported operative mortality (0% in each group), there was no report of operative morbidity or functional outcome.

CONCLUSION

The optimal surgical approach in the management of HNPCC remains unclear. More adenomas and cancers occur after SC than after TC but there certainly is no evidence to suggest that more radical surgery leads to improved survival.

Is prophylactic surgery for femoroacetabular impingement indicated? A systematic review

BACKGROUND

This is a systematic review to determine if prophylactic surgical intervention for asymptomatic patients with radiographic evidence of femoroacetabular impingement (FAI) is warranted to prevent early degenerative joint disease of the hip.

METHODS

A systematic search was performed from 1965 to 2013 in PubMed and EMBASE. Inclusion criteria were prospective or retrospective studies comparing skeletally mature asymptomatic patients with radiographic evidence of FAI treated with prophylactic hip arthroscopic surgery versus nonoperative management. A total of 840 references were identified from the searches. After detailed eligibility screening, none of the references met the eligibility criteria.

RESULTS

No trials were identified that met the criteria for inclusion in the review.

CONCLUSION

There is a lack of available evidence to support surgical intervention for the treatment of FAI in asymptomatic patients. This article attempts to address this dilemma by reviewing the available literature to answer several questions that would indirectly address the topic. First, what is the prevalence of FAI in the asymptomatic population? Second, what is the natural history of FAI if left untreated? Upon reviewing these issues, the authors' conclusion parallels that of the systematic review: Current evidence does not support prophylactic surgery for asymptomatic FAI in the vast majority of cases. However, limited evidence suggests that asymptomatic patients who have previously undergone total hip arthroplasty for FAI-induced osteoarthritis of the contralateral hip are at a significantly increased risk for early degenerative joint disease. Further research is needed to better clarify surgical indications.

Prophylactic colectomy: Rationale, indications, and approach

Discerning the genetics of hereditary colorectal cancer syndromes has enabled a more individualized approach to preventing and treating colorectal cancers in affected patients and families. As these syndromes carry significant risk of colorectal cancer (nearly 100% in some cases), prophylactic colectomy is an important option for preventing cancer. This article addresses the rationale and indications for prophylactic colectomy in hereditary colorectal cancer syndromes, and provides insight into the details of surgical management.

Breast cancer prevention

Breast cancer is the most common cancer in women with 232,670 new cases estimated in the USA for 2014. Approaches for reducing breast cancer risk include lifestyle modification, chemoprevention, and prophylactic surgery. Lifestyle modification has a variety of health benefits with few associated risks and is appropriate for all women regardless of breast cancer risk. Chemoprevention options have expanded rapidly, but most are directed at estrogen receptor positive breast cancer and uptake is low. Prophylactic surgery introduces significant additional risks of its own and is generally reserved for the highest risk women.

Current strategies for the prevention of breast cancer

Due to the high incidence of breast cancer in the United States, optimal strategies for its prevention are imperative. This entails identification of women who are at an increased risk for breast cancer and an integrative approach that includes effective screening methods as well as nutritional, pharmacologic, and surgical management. Several breast cancer risk-assessment tools, such as the Gail and Claus models, can help clinicians determine the quantitative risk of breast cancer. The role of selective estrogen receptor modulators, such as tamoxifen and raloxifene, for the prevention of breast cancer has been well established. Several other agents, such as aromatase inhibitors, are currently being investigated. The potential adverse effects of these chemopreventive agents, which include an impact on the quality of life, must be discussed with the patient before deciding on this approach. Additionally, breast cancer risk factors have been identified over the years; some of them are modifiable, but others are not. Although there is no conclusive evidence to suggest the protective role of specific dietary components, alcohol consumption and obesity are associated with an increased breast cancer risk; thus lifestyle changes can lead to a lower risk of developing breast cancer. Surgical approaches, including bilateral risk-reduction mastectomy and salpingo-oophorectomy, are usually limited to women with a hereditary predisposition to development of breast cancer. The objective of this review is to summarize the various approaches directed at reducing the incidence of breast cancer.

The psychological impact of breast and ovarian cancer preventive options in BRCA1 and BRCA2 mutation carriers

This study was performed to describe the impact of preventive options on the psychological condition of BRCA1/BRCA2 carriers. A sample of 52 cancer-affected (C-A) and 27 cancer-unaffected (C-UN) women were enrolled after gene test disclosure (T0). Psychological evaluations were performed at T0 and 15 months later (T1). The surgical options were more likely to be chosen in C-A women (62%), although a consistent proportion of C-UN women (30%) also opt for these preventive measures. At the baseline, both samples had average anxiety and depression scores below the cut-off value, restrained average cancer worry scores and a risk perception consistent with the risk percentage provided during genetic counselling. The longitudinal results indicated no clinically meaningful variations in the anxiety and depression scores in either of the two samples. Statistically significant reductions in cancer-risk perception emerged in women who chose surgery in both C-A and C-UN women. In BRCA1/BRCA2 mutation carriers, surveillance does not influence their initial psychological condition, whereas prophylactic surgery has a significant impact in reducing the perceived risk and worry about getting sick. C-A and C-UN women have to be considered as two separate populations of BRCA mutation carriers requiring personalized approaches to risk management.

The impact of risk-reducing hysterectomy and bilateral salpingo-oophorectomy on survival in patients with a history of breast cancer--a population-based data linkage study

Prophylactic surgery including hysterectomy and bilateral salpingo-oophorectomy (BSO) is recommended in breast cancer susceptibility gene (BRCA)-positive women, whereas in women from the general population, hysterectomy plus BSO may increase the risk of overall mortality. The effect of hysterectomy plus BSO on women previously diagnosed with breast cancer is unknown. We used data from a population-base data linkage study of all women diagnosed with primary breast cancer in Queensland, Australia between 1997 and 2008 (n = 21,067). We fitted flexible parametric breast cancer-specific and overall survival models with 95% confidence intervals (also known as Royston-Parmar models) to assess the impact of risk-reducing surgery (removal of uterus, one or both ovaries). We also stratified analyses by age 20-49 and 50-79 years, respectively. Overall, 1,426 women (7%) underwent risk-reducing surgery (13% of premenopausal women and 3% of postmenopausal women). No women who had risk-reducing surgery compared to 171 who did not have risk-reducing surgery developed a gynaecological cancer. Overall, 3,165 (15%) women died, including 2,195 (10%) from breast cancer. Hysterectomy plus BSO was associated with significantly reduced risk of death overall [adjusted hazard ration (HR), 0.69; 95% confidence interval (CI), 0.53-0.89; p = 0.005]. Risk reduction was greater among premenopausal women, whose risk of death halved (HR, 0.45; 95% CI, 0.25-0.79; p < 0.006). This was largely driven by reduction in breast cancer-specific mortality (HR, 0.43; 95% CI, 0.24-0.79; p < 0.006). This population-based study found that risk-reducing surgery halved the mortality risk for premenopausal breast cancer patients. Replication of our results in independent cohorts and subsequently randomised trials are needed to confirm these findings.

Endometrial and ovarian cancer in lynch syndrome

Lynch syndrome (LS) is an autosomal dominant familial cancer risk syndrome that occurs due to a germline mutation in one of several mismatch repair genes and is associated with an increased risk of colorectal, endometrial, and ovarian cancer. The risk of endometrial cancer equals or exceeds that of colorectal cancer in women with LS. The diagnosis of gynecologic cancer precedes that of colorectal cancer in over half of women with metachronous gynecologic and colon cancers, making gynecologic cancer a "sentinel cancer" for LS. There are no studies addressing the effectiveness or safety of chemoprevention for women with LS. Surveillance with gynecologic examination including assessment of symptoms, transvaginal pelvic ultrasonography, endometrial biopsy, and CA125 tumor marker assessment can be offered, but has not been shown to improve outcomes for these patients. Prophylactic hysterectomy with bilateral salpingo-oophorectomy performed after the completion of childbearing may be offered for gynecologic cancer prevention.

Surgical treatment of Duchenne muscular dystrophy patients in Germany: the present situation

In 1988, we familiarised ourselves at Poitiers with the concept of operative treatment of the lower limbs and the spine in Duchenne muscular dystrophy (DMD) patients which Yves Rideau and his collaborators had developed there in the early 1980s. Thereupon, we immediately established the techniques at our home universities, first at the Technische Universität Aachen and, from 1999 on, at the Universitätsklinikum Erlangen, Germany. Since then, we have applied the technique to more than 500 DMD patients in total by performing more than 800 operations on the lower limbs and/or spine. In support of findings reported by Professor Rideau in this issue we observed that, where patients are still ambulatory at the time of operation, the operation delays the point at which patients become wheelchair-bound by about two years. Likewise, patients receiving this treatment were/are also able to perform the Gowers' manoeuvre for around two years longer.

Congenital spinal lipomas: Role of prophylactic surgery

INTRODUCTION

Congenital spinal lipomas constitute an important group of lesions causing tethered cord syndrome. Management of these lesions is challenging and role of prophylactic surgery for these lesions is still controversial. Hence, current study was undertaken with the aim to evaluate the role of prophylactic surgery in the management of these lesions.

MATERIALS AND METHODS

A total of 147 consecutive patients, treated over a period of 10 years (January 2001-December 2010), are retrospectively analyzed.

RESULTS

In our study, 93 patients had conus lipomas, 26 had filum lipomas and 28 had only lipomeningomyelocele. Boys and girls were almost equally represented. The age of patients at the time of surgery ranged from 15 days to 34 years with an average of 62 months (5.2 years). Neurological deficits were present in 101 (68) patients. The patients with neurological deficits were older in comparison to those neurologically intact (average age 6.2 versus 2.8 years, respectively). Difference in age between the two groups was statistically significant (P value 0.03). Neurological deterioration was observed in 8 (5) patients following surgery, out of which six patients developed transient deterioration and only two, had persisting deficits. None of the neurologically asymptomatic patients developed persistent neurological deficits. In the symptomatic group, nine patients (9) showed improvement in neurological status after surgery.

CONCLUSIONS

In author's view, prophylactic surgery for congenital spinal lipomas is safe and effective. However, a well designed randomized controlled trial, to definitely and objectively prove the usefulness of prophylactic surgery is needed.

Split cord malformation - A study of 300 cases at AIIMS 1990-2006

BACKGROUND

Split cord malformation (SCM) is a rare condition. With decreasing incidence of neural tube defect (NTD) in the West, the reports of SCM are getting lesser and lesser. However, in India, spinal dysraphism is still a major problem encountered by the neurosurgeons.

OBJECTIVE

Our aim was to analyze 300 patients of SCM for their clinical features, radiological findings and outcome of surgery, which can throw light on the subject to others, who have less scope of finding these cases frequently.

MATERIALS AND METHODS

Over a 16-year period, we encountered 300 cases of SCM at AIIMS. Over the same period, more than 1500 cases of NTD were managed. SCM was noticed in 20% of cases with NTD. Skin stigmata were noted in two-third of the cases, and scoliosis and foot deformity were observed in 50% and 48% cases, respectively. Motor and sensory deficits were observed in 80% and 70% cases, respectively. Commonest site affected was lumbar or dorsolumbar (55% and 23%, respectively). In 3% cases, it was cervical in location. Magnetic resonance imaging (MRI) scan revealed a large number of anomalies like lipoma, neuroenteric cyst, thick filum and dermoid or epidermoid cysts. All the patients were surgically treated. In type I, bony spurs were excised, and in type II, bands tethering the cord were released. Associated anomalies were managed in the same sitting. Patients were followed up from 3 months to 3 years.

RESULTS

Overall improvement was noticed in 50% and stabilization in 44% cases and deterioration of neurological status was recorded in 6% cases. However, 50% of those who deteriorated improved to preop status prior to discharge, 7-10 days following surgery.

CONCLUSIONS

SCM is rare and not many large series are available. We operated 300 cases and noticed a large number of associated anomalies and also multilevel and multisite splits. Improvement or stabilization was noted in 94% and deterioration in 6% cases. We recommended prophylactic surgery for our asymptomatic patients.

Juvenile polyposis syndrome

AIM

Report of a series of 12 cases of juvenile polyposis coli.

METHODS

The study period was from 1995 to 2005. All the patients were treated by total colectomy with rectal mucosectomy and endorectal ileoanal pullthrough with or without ileal pouch formation. Covering ileostomy was avoided in all the cases. Time taken for the surgery, postoperative complications and continence were documented.

RESULTS

The mean operating time was 4.2 h (range: 4-5 h). The mean duration of hospital stay was 16.3 days (range: 15-18 days). The most common postoperative complication was pouchitis and perianal excoriation. Initially, all the patients were passing stools at an interval of 2 h, and after 3 weeks, the frequency has reduced to 6-8 stools per day. In the follow-up after 3 months, the frequency was 3-5 per day with minimal soiling.

CONCLUSIONS

Single-stage total colectomy with rectal mucosectomy and endorectal ileoanal pull-through without covering ileostomy and pouch formation is a safe and definitive treatment for juvenile polyposis coli if the patient selection is appropriate.