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JACS CME-1 Featured Article, Volume 206, April 2008
CONTINUING MEDICAL EDUCATION PROGRAM
JACS CME-1 FEATURED ARTICLE, VOLUME 206, APRIL 2008 Current role of therapeutic laparoscopy and thoracoscopy in the management of malignancy: a review of trends from a tertiary care cancer center Are C, Brennan MF, D’Angelica MA, et al J am Coll Surg 2008;206:709–718 Current progress in keloid research and treatment Butler PD, Longaker MT, Yang GP J Am Coll Surg. 2008;206:731–741 You can earn 4 CME credits using JACS CME Online, at http://jacscme.facs.org, or you can earn 2 CME credit if you submit this page by fax (see instructions in box below). JACS CME Online provides four articles from each issue for 4 credits per month. The articles this month on JACS CME Online are: Current role of therapeutic laparoscopy and thoracoscopy in the management of malignancy: a review of trends from a tertiary care cancer center. Are C, Brennan MF, D’Angelica MA, et al. Current progress in keloid research and treatment. Butler PD, Longaker MT, Yang GP. Neoadjuvant chemotherapy in invasive breast cancer results in a lower axillary lymph node count. Bélanger J, Soucy G, Sidéris L, et al. Age-related differences in diagnosis and morbidity of intestinal malrotation. Durkin ET, Lund DP, Shaaban AF, et al.
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in the JACS CME program should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. Objectives are stated at the beginning of each featured article; the questions follow with five response choices, and a critique discussing the objective. The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The JACS CME program fulfills the ACCME essentials. The American College of Surgeons designates this educational activity for a maximum of 2 Category 1 credits toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/ she actually spent in the educational activity.
Questions: Wendy Cowles Husser, MA, MPA Executive Editor, JACS 633 N Saint Clair Street, Chicago, IL 60611 312-202-5306 (ph) 312-202-5027 (fax) [email protected]
© 2008 by the American College of Surgeons Published by Elsevier Inc.
764
ISSN 1072-7515/08/$34.00 doi:10.1016/j.jamcollsurg.2008.01.001
Vol. 206, No. 4, April 2008
Current role of therapeutic laparoscopy and thoracoscopy in the management of malignancy: a review of trends from a tertiary care cancer center
Are C, Brennan MF, D’Angelica MA, et al J Am Coll Surg 2008;206:709–718
Learning Objectives: After studying this article, the reader will understand the role and current indications/ limitations of laparoscopic and thoracoscopic approaches to malignant conditions. Question 1
With regard to the laparoscopic approach to malignancies involving various organ systems, which is the correct answer? a) Laparoscopy is of minimal benefit is women with adnexal masses and a history of previous non-gynecologic malignancy. b) VATS is currently utilized to treat patients with small cell lung cancer. c) Data from well conducted randomized controlled trials have established the safety and oncologic adequacy of the laparoscopic approach to colon cancer. d) Data from well conducted randomized controlled trials have established the safety and oncologic adequacy of the laparoscopic approach to rectal cancer. e) The choice of approach for patients with suspected metastasis to the adrenal gland is by the open approach.
Critique: Laparoscopy is beneficial in women with adnexal masses and a prior history of non gynecologic malignancy. Evidence in literature reports in this group of patients a high risk of malignancy (up to 18.7%). The majority of patients usually have a history of previous breast carcinoma. Although most of these patients harbor a metastatic lesion in the adnexa, at least one-third of the patients are noted to have a primary ovarian malignancy. VATS is currently used to treat patients with non smallcell lung cancer (NSCLC) of stage I (only) and a size limit of 4 cm. Three well conducted randomized trials have demonstrated the safety and oncologic adequacy of the laparoscopic approach to colon cancer compared with the open approach. Two trials adequately demonstrated the safety and oncologic adequacy of laparoscopy and serve as the justification for the laparoscopic approach to colon cancer (see article). There are no randomized trials that have specifically addressed the issue of the laparoscopic approach to rectal cancer, although several retrospective studies have confirmed the safety (references 41–49 article). The only randomized trial to include a significant number of patients
Continuing Medical Education Program
765
with rectal cancer was the MRC CLASSIC trial (reference 41 in article). Laparoscopy is currently the procedure of choice in selected patients with lesions involving the adrenal gland (benign functional, primary, and metastatic lesions). Question 2
With regard to the laparoscopic approach to hepatic and pancreatic lesions, which is the correct answer? a) More hepatic wedge resections are performed by the laparoscopic approach in comparison to the open approach. b) Laparoscopy is ideally suited for patients with lesions in segments I, VII and VIII of the liver. c) Patients with focal nodular hyperplasia of the liver should be treated by the laparoscopic approach. d) Splenic preservation is not recommended during laparoscopic distal pancreatectomy for cystic/pre malignant lesions. e) The standard approach for patients with a solid lesion in the body/tail of the pancreas is by laparoscopy.
Critique: Although there are no randomized trials or retrospective studies with a large series of patients, it is generally believed that the laparoscopic approach is best suited for patients with isolated lesions in the accessible segments (segments II–VI). Laparoscopic wedge resections are also easier procedures to master before embarking on more substantial segmental/sectoral resections. The laparoscopic approach is best suited for lesions in the accessible segments of the liver (segments II–VI). The majority of patients with lesions in segments I, VII, and VIII are best treated by the open approach. Focal nodular hyperplasia is a benign diagnosis with no potential for malignant transformation and should not be operated upon by either approach (open or laparoscopic) unless there are symptoms or the diagnosis is in doubt. The diagnosis of focal nodular hyperplasia can be made accurately with the help of CT scan/MRI. The availability of technology should not lower the threshold to operate on patients who otherwise would not have been operated in pre-laparoscopy era. Preservation of the spleen should be attempted in patients undergoing laparoscopic distal pancreatectomy for cystic/pre malignant lesions. Although technically more demanding, it is appropriate, particularly if the final histopathology reveals a benign diagnosis. On the other hand, any suspicion of carcinoma on pre operative radiologic workup usually leads to splenectomy. Although there are no data, in patients with a clear diagnosis of adenocarcinoma on preoperative work up, current thinking is to proceed with the open approach to
766
Continuing Medical Education Program
enable an oncologically adequate operation, which usually includes splenectomy. Current progress in keloid research and treatment
Butler PD, Longaker MT, Yang GP J Am Coll Surg. 2008;206:731–741
Learning Objectives: After study of this article, the surgeon will develop an understanding of the current state of knowledge concerning keloid pathogenesis, and the potential treatment modalities for keloids and their efficacies. Question 1
Which of the following statements concerning keloid pathology is correct? a) Keloids are dermal fibroproliferative tumors unique to humans with malignant potential. b) Keloids have an abnormal epidermal layer, abundant vasculature, thickened dermis, and increased inflammatorycell infiltrate when compared to normal scar tissue. c) Research suggests that keloid scars may be the result of enhanced catabolic activity. d) Apoptosis, or programmed cell death, is not an important component of wound healing. e) Increase expression of pro-fibrotic growth factors, including Transforming Growth Factor (TGF)- and Connective Tissue Growth Factor (CTGF, CCN2), has been implicated in the pathogenesis of keloid scars.
Critique: Keloid scars are indeed dermal fibroproliferative tumors that are unique to humans, but they have no malignant potential. Their morbidity comes from the considerable cosmetic defect that they produce and the fact that some can grow large enough to become symptomatic by causing deformity or limiting joint mobility. Histologically, keloid scars have abundant vasculature, thickened dermis, and increased inflammatory-cell infiltrate when compared to normal scars; however, their epidermal layer has a normal appearance. This is why the bulk of keloid research has been aimed at keloid fibroblast, which are the predominant cells found in the abnormally thickened dermal layer. The majority of keloid research has focused primarily on an enhanced anabolic process, but recently there has been increased focus on the possibility of decreased catabolic activity in keloid scars. Part of this catabolic activity requires certain cells within the wound to carry out programmed cell death, or apoptosis, which is a fundamental component of appropriate cutaneous healing.
J Am Coll Surg
There are numerous cytokines that play a role in the wound healing process. The increased expression of TGF and CTGF in keloid compared to normal scar has been one of the most heavily studied. Their increased expression is believed involved in keloid pathogenesis although the specific mechanisms remain unknown. Question 2
Which of the following statements regarding the presentation and treatment of keloid scars is correct? a) Both keloid and hypertrophic scars are similar in that they do not regress and they grow continuously beyond the original margins of the scar. b) Keloid scars are rarely erythematous or pruritic. c) There is evidence that surgical excision combined with immediate post-operative brachytherapy has resulted in less than a 10% recurrence rate. d) Surgical excision as a monotherapy has been an effective therapy for the treatment of keloids. e) Intralesional triamcinolone acetone injections as a monotherapy have been a relatively successful modality for the treatment of keloids with few side effects.
Critique: The two prominent features that distinguish keloid scars from both hypertrophic scars and normal scars are that they do not regress over time and that they grow beyond the original margins of the scar. Upon presentation, keloid scars actually “invade” the skin beyond the perimeter of the original wound and it is not uncommon for them to have a leading edge that is erythematous and pruritic. Surgical excision as a monotherapy has been repeatedly proven to be ineffective, with reported recurrence rates of 55–100 %. Intralesional triamcinolone acetone injections as a monotherapy has been successful in some hands; however, the requirement of multiple injections, along with the side effects of injection pain, skin atrophy, telangiectasias, and altered pigmentation have caused clinicians and researchers to continue to look for other means of treatment. Despite the failure of surgical excision alone, when excision is followed by radiotherapy there appears to be a relatively good result. Particularly, the use of high dose brachytherapy after surgical excision has revealed a keloid scar recurrence rate of less than 10% in one fairly large study. Unfortunately, these results have not been uniform among different practitioners and there are always additional risks with radiation therapy, including the late development of malignancies, which has made radiation oncologists reluctant to use this routinely.
JACS CME-1 FEATURED ARTICLE, VOLUME 206, APRIL 2008 Current role of therapeutic laparoscopy and thoracoscopy in the management of malignancy: a review of trends from a tertiary care cancer center Are C, Brennan MF, D’Angelica MA, et al J am Coll Surg 2008;206:709–718 Current progress in keloid research and treatment Butler PD, Longaker MT, Yang GP J Am Coll Surg. 2008;206:731–741 You can earn 4 CME credits using JACS CME Online, at http://jacscme.facs.org, or you can earn 2 CME credit if you submit this page by fax (see instructions in box below). JACS CME Online provides four articles from each issue for 4 credits per month. The articles this month on JACS CME Online are: Current role of therapeutic laparoscopy and thoracoscopy in the management of malignancy: a review of trends from a tertiary care cancer center. Are C, Brennan MF, D’Angelica MA, et al. Current progress in keloid research and treatment. Butler PD, Longaker MT, Yang GP. Neoadjuvant chemotherapy in invasive breast cancer results in a lower axillary lymph node count. Bélanger J, Soucy G, Sidéris L, et al. Age-related differences in diagnosis and morbidity of intestinal malrotation. Durkin ET, Lund DP, Shaaban AF, et al.
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in the JACS CME program should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. Objectives are stated at the beginning of each featured article; the questions follow with five response choices, and a critique discussing the objective. The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The JACS CME program fulfills the ACCME essentials. The American College of Surgeons designates this educational activity for a maximum of 2 Category 1 credits toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/ she actually spent in the educational activity.
Questions: Wendy Cowles Husser, MA, MPA Executive Editor, JACS 633 N Saint Clair Street, Chicago, IL 60611 312-202-5306 (ph) 312-202-5027 (fax) [email protected]
© 2008 by the American College of Surgeons Published by Elsevier Inc.
764
ISSN 1072-7515/08/$34.00 doi:10.1016/j.jamcollsurg.2008.01.001
Vol. 206, No. 4, April 2008
Current role of therapeutic laparoscopy and thoracoscopy in the management of malignancy: a review of trends from a tertiary care cancer center
Are C, Brennan MF, D’Angelica MA, et al J Am Coll Surg 2008;206:709–718
Learning Objectives: After studying this article, the reader will understand the role and current indications/ limitations of laparoscopic and thoracoscopic approaches to malignant conditions. Question 1
With regard to the laparoscopic approach to malignancies involving various organ systems, which is the correct answer? a) Laparoscopy is of minimal benefit is women with adnexal masses and a history of previous non-gynecologic malignancy. b) VATS is currently utilized to treat patients with small cell lung cancer. c) Data from well conducted randomized controlled trials have established the safety and oncologic adequacy of the laparoscopic approach to colon cancer. d) Data from well conducted randomized controlled trials have established the safety and oncologic adequacy of the laparoscopic approach to rectal cancer. e) The choice of approach for patients with suspected metastasis to the adrenal gland is by the open approach.
Critique: Laparoscopy is beneficial in women with adnexal masses and a prior history of non gynecologic malignancy. Evidence in literature reports in this group of patients a high risk of malignancy (up to 18.7%). The majority of patients usually have a history of previous breast carcinoma. Although most of these patients harbor a metastatic lesion in the adnexa, at least one-third of the patients are noted to have a primary ovarian malignancy. VATS is currently used to treat patients with non smallcell lung cancer (NSCLC) of stage I (only) and a size limit of 4 cm. Three well conducted randomized trials have demonstrated the safety and oncologic adequacy of the laparoscopic approach to colon cancer compared with the open approach. Two trials adequately demonstrated the safety and oncologic adequacy of laparoscopy and serve as the justification for the laparoscopic approach to colon cancer (see article). There are no randomized trials that have specifically addressed the issue of the laparoscopic approach to rectal cancer, although several retrospective studies have confirmed the safety (references 41–49 article). The only randomized trial to include a significant number of patients
Continuing Medical Education Program
765
with rectal cancer was the MRC CLASSIC trial (reference 41 in article). Laparoscopy is currently the procedure of choice in selected patients with lesions involving the adrenal gland (benign functional, primary, and metastatic lesions). Question 2
With regard to the laparoscopic approach to hepatic and pancreatic lesions, which is the correct answer? a) More hepatic wedge resections are performed by the laparoscopic approach in comparison to the open approach. b) Laparoscopy is ideally suited for patients with lesions in segments I, VII and VIII of the liver. c) Patients with focal nodular hyperplasia of the liver should be treated by the laparoscopic approach. d) Splenic preservation is not recommended during laparoscopic distal pancreatectomy for cystic/pre malignant lesions. e) The standard approach for patients with a solid lesion in the body/tail of the pancreas is by laparoscopy.
Critique: Although there are no randomized trials or retrospective studies with a large series of patients, it is generally believed that the laparoscopic approach is best suited for patients with isolated lesions in the accessible segments (segments II–VI). Laparoscopic wedge resections are also easier procedures to master before embarking on more substantial segmental/sectoral resections. The laparoscopic approach is best suited for lesions in the accessible segments of the liver (segments II–VI). The majority of patients with lesions in segments I, VII, and VIII are best treated by the open approach. Focal nodular hyperplasia is a benign diagnosis with no potential for malignant transformation and should not be operated upon by either approach (open or laparoscopic) unless there are symptoms or the diagnosis is in doubt. The diagnosis of focal nodular hyperplasia can be made accurately with the help of CT scan/MRI. The availability of technology should not lower the threshold to operate on patients who otherwise would not have been operated in pre-laparoscopy era. Preservation of the spleen should be attempted in patients undergoing laparoscopic distal pancreatectomy for cystic/pre malignant lesions. Although technically more demanding, it is appropriate, particularly if the final histopathology reveals a benign diagnosis. On the other hand, any suspicion of carcinoma on pre operative radiologic workup usually leads to splenectomy. Although there are no data, in patients with a clear diagnosis of adenocarcinoma on preoperative work up, current thinking is to proceed with the open approach to
766
Continuing Medical Education Program
enable an oncologically adequate operation, which usually includes splenectomy. Current progress in keloid research and treatment
Butler PD, Longaker MT, Yang GP J Am Coll Surg. 2008;206:731–741
Learning Objectives: After study of this article, the surgeon will develop an understanding of the current state of knowledge concerning keloid pathogenesis, and the potential treatment modalities for keloids and their efficacies. Question 1
Which of the following statements concerning keloid pathology is correct? a) Keloids are dermal fibroproliferative tumors unique to humans with malignant potential. b) Keloids have an abnormal epidermal layer, abundant vasculature, thickened dermis, and increased inflammatorycell infiltrate when compared to normal scar tissue. c) Research suggests that keloid scars may be the result of enhanced catabolic activity. d) Apoptosis, or programmed cell death, is not an important component of wound healing. e) Increase expression of pro-fibrotic growth factors, including Transforming Growth Factor (TGF)- and Connective Tissue Growth Factor (CTGF, CCN2), has been implicated in the pathogenesis of keloid scars.
Critique: Keloid scars are indeed dermal fibroproliferative tumors that are unique to humans, but they have no malignant potential. Their morbidity comes from the considerable cosmetic defect that they produce and the fact that some can grow large enough to become symptomatic by causing deformity or limiting joint mobility. Histologically, keloid scars have abundant vasculature, thickened dermis, and increased inflammatory-cell infiltrate when compared to normal scars; however, their epidermal layer has a normal appearance. This is why the bulk of keloid research has been aimed at keloid fibroblast, which are the predominant cells found in the abnormally thickened dermal layer. The majority of keloid research has focused primarily on an enhanced anabolic process, but recently there has been increased focus on the possibility of decreased catabolic activity in keloid scars. Part of this catabolic activity requires certain cells within the wound to carry out programmed cell death, or apoptosis, which is a fundamental component of appropriate cutaneous healing.
J Am Coll Surg
There are numerous cytokines that play a role in the wound healing process. The increased expression of TGF and CTGF in keloid compared to normal scar has been one of the most heavily studied. Their increased expression is believed involved in keloid pathogenesis although the specific mechanisms remain unknown. Question 2
Which of the following statements regarding the presentation and treatment of keloid scars is correct? a) Both keloid and hypertrophic scars are similar in that they do not regress and they grow continuously beyond the original margins of the scar. b) Keloid scars are rarely erythematous or pruritic. c) There is evidence that surgical excision combined with immediate post-operative brachytherapy has resulted in less than a 10% recurrence rate. d) Surgical excision as a monotherapy has been an effective therapy for the treatment of keloids. e) Intralesional triamcinolone acetone injections as a monotherapy have been a relatively successful modality for the treatment of keloids with few side effects.
Critique: The two prominent features that distinguish keloid scars from both hypertrophic scars and normal scars are that they do not regress over time and that they grow beyond the original margins of the scar. Upon presentation, keloid scars actually “invade” the skin beyond the perimeter of the original wound and it is not uncommon for them to have a leading edge that is erythematous and pruritic. Surgical excision as a monotherapy has been repeatedly proven to be ineffective, with reported recurrence rates of 55–100 %. Intralesional triamcinolone acetone injections as a monotherapy has been successful in some hands; however, the requirement of multiple injections, along with the side effects of injection pain, skin atrophy, telangiectasias, and altered pigmentation have caused clinicians and researchers to continue to look for other means of treatment. Despite the failure of surgical excision alone, when excision is followed by radiotherapy there appears to be a relatively good result. Particularly, the use of high dose brachytherapy after surgical excision has revealed a keloid scar recurrence rate of less than 10% in one fairly large study. Unfortunately, these results have not been uniform among different practitioners and there are always additional risks with radiation therapy, including the late development of malignancies, which has made radiation oncologists reluctant to use this routinely.