Bassiouny, M., H. H. El-Marakby, N. Saber, S. B. Zayed, and A. Shokry, "Quadrantectomy and nipple saving mastectomy in treatment of early breast cancer: feasibility and aesthetic results of adjunctive latissmus dorsi breast reconstruction.", Journal of the Egyptian National Cancer Institute, vol. 17, issue 3, pp. 149-57, 2005. Abstract

BACKGROUND AND PURPOSE: Breast conserving surgery has been a recognised method of treatment of early breast cancer. The treatment methods include quadrantectomy or skin sparing mastectomy combined with ipsilateral axillary nodal dissection followed by radiotherapy. In the current study we evaluate the feasibility and oncologic safety of the quadrantectomy and SSM operations with preservation of the nipple and areola, and the cosmetic results of immediate reconstruction by using the latissmus dorsi flap.

MATERIALS AND METHODS: A breast conservative surgery (quadrantectomy or nipple sparing mastectomy) was carried out in a group of 55 patients with invasive breast cancer treated at the Department of Surgical Oncology, NCI, between January 2001 and April 2004. The selection criteria included those patients who presented with T1 or T2 breast cancer and were located at least 2 cm from the nipple as the centre for the nipple areola complex.

RESULTS: The age of the patients ranged from 32 years to 65 years. The follow up period ranged from 2 to 33 months with an average of 21 months. Pathological assessment of the specimens showed a negative safety margin in all cases. Most of our cases were invasive duct carcinoma grade 1-2 (42) (75%). The complications of the flap reconstruction included one major sloughing of the latissmus dorsi flap, 4 partial flap sloughing, 4 sloughing of the nipple and fat necrosis in 6 patients. The donor site healed normally in all of our cases except for one patient who suffered from a hypertrophic scar which settled down during the follow up period. The aesthetic assessment of the patients, showed an excellent to good results in the majority of cases (42) (75%) while in 6 (12%) results were fair and in 7 (13%) results were poor.

CONCLUSION: Breast conservative surgery with quadrantectomy or skin sparing technique with preservation of the nipple and areola combined with immediate LD flap reconstruction is a valid procedure for treatment of early breast cancer. Immediate reconstruction by using the extended latissmus dorsi is as safe, relatively easy procedure which can provide an adequate volume replacement for small to moderate sized breasts.

El-Marakby, H. H., "The versatile naso-labial flaps in facial reconstruction.", Journal of the Egyptian National Cancer Institute, vol. 17, issue 4, pp. 245-50, 2005. Abstract

BACKGROUND: Surgical excision of tumors from the face may create a defect that is difficult to restore. Skin grafts can only cover superficial defects and has a natural tendency to contract and may not take properly. Also, because of the colour mismatch, it is not cosmetically identical to the face. The use of regional flaps such as the median forehead flaps are usually bulky, can not cover a wide range of facial reconstruction and usually require the donor area to be grafted. The naso-labial flaps are very useful and versatile local flaps, with robust vascularity that can be readily elevated without a delay. The flap can be superiorly based to reconstruct defects on the cheek, side wall or the dorsum of the nose, alae, collumula and the lower eye lid. Inferiorly based flaps can be used to reconstruct defects in the upper lip, anterior floor of the mouth and the lower lip. The flap can be turned over and used as a lining of the nose and the lip.

AIM OF THE STUDY: In the current study we present our experience with utilization of the nasolabial flaps in facial reconstruction. We evaluated the indications, flap designs, technique, and complications. We will also assess the final functional and aesthetic results.

MATERIAL AND METHODS: The study included 20 patients (12 males and 8 females) presented at the surgical department, National Cancer Institute (NCI) Cairo University with skin cancer at different areas of the face. Preoperative assessment includes. Assessment of the stage of the disease, the flap design and patient general condition.

RESULTS: The mean age of the patients was 56.3 +/-6 years (range 16-62 years). Fifteen patients presented with basal cell carcinoma, 2 squamous cell carcinoma, one malignant melanoma, one keratoacanthoma, and one xeroderma pigmentosa. Nasal defects constituted 75% of cases, the rest were lower eye lid (2), one upper lip and one oral commisure beside a case of cheek reconstruction. There was no major complication; only one patient suffered a reactionary hemorrhage that required re-exploration to secure the bleeder. A single procedure was adequate in most of the patients (80%), only 4 patients required revision of the scar at the donor site. The overall aesthetic results were very satisfactory in the majority of patients (16), and satisfactory in 2 cases. Only 2 patients were not satisfied by the final aesthetic results, one suffered from ectropion and the other had a donor site wound healing problem.

CONCLUSION: The nasolabial flap is a versatile, simple, easy to harvest local flap that can cover a variety of defects in the face. It is ideally suitable for covering small and moderate sized defects in the eye lid, cheek, nose, the anterior floor of the mouth and the lip.

El-Marakby, H. H., "The reliability of pectoralis major myocutaneous flap in head and neck reconstruction.", Journal of the Egyptian National Cancer Institute, vol. 18, issue 1, pp. 41-50, 2006. Abstract

BACKGROUND: The pectoralis major myocutaneous pedicle flap (PMMPF) has been considered to be the "workhorse" of pedicled flaps in head and neck reconstruction. Several series of PMMPF procedures in head and neck reconstruction have been reported in the literature. Even with the worldwide use of free flaps, the flap is still considered the mainstay head and neck reconstructive procedures in many centers. However, the flap is usually associated with a high incidence of complications in addition to its large bulk compared with the free fasciocutaneous flaps. Also the final functional and the aesthetic results are not comparable to free flaps head and neck reconstruction.

AIM OF THE STUDY: The aim of the study is to evaluate the reliability of such flap in selected cases of head and neck reconstruction. The indications, technique, complications and the functional as well as the aesthetic results of the flap utilization were evaluated.

PATIENTS AND METHODS: Between May 2002 and May 2005 a 26 consecutive head and neck reconstruction procedures using the PMMPF were carried out on 25 patients at the Department of Surgery, National Cancer Institute, Cairo University. The indications for the flap use were defects due to resection of stage II-IV cancer in the head and neck region. The site, stage of the disease and the presence or absence of distant metastasis were assessed. Also preoperative assessment included the fitness of patients for such an extensive procedure. The total operative time, the need for blood transfusion, the postoperative complications, were all documented. The length of hospital stay, the follow-up of patients as well as the incidence of local recurrence underneath the flap were all evaluated.

RESULTS: Pectoralis major myocutaneous pedicled flap reconstructions were used to reconstruct defects in the following sites: oral cavity (10 patients); oropharynx/ hypopharynx, (5 patients); and neck or face (10 patients). Of the 26 PMMPF reconstructions, 22 flaps were carried out as primary reconstructive procedures, whereas 4 flaps were "salvage" procedures (reconstruction after fistula, free flap failure, coverage of exposed mandibular prosthesis). Fifteen patients (60%) had complications such as wound dehiscence, infection, hematoma, seroma, partial flap failure, total flap failure, fistula, and donor site complications. A higher complication rates were associated with the utilization of the flap as a salvage procedure, number of co morbidities, and in oral cavity reconstructions.

CONCLUSION: Although the PMMPF is a versatile flap in head and neck reconstruction, being in the proximity of the region with good reach to different areas of the face, oral cavity, and the pharynx; the flap is fraught with a high complication rate. The wide use and the reliability of free flaps in head and neck reconstruction have superseded the use of the PMMPF flap in comparable circumstances. However, the flap still has a place in head and neck reconstruction, particularly after resection of locally advanced tumours. Also the flap can be still used as a salvage procedure after free flaps failure or when there is a shortage of the microsurgery facility.

NAGUIB, S. H. E. R. I. F. F., A. S. Zaghloul, and H. elmarakby, "Gastrointestinal stromal tumors (GIST) of the stomach: retrospective experience with surgical resection at the National Cancer Institute.", Journal of the Egyptian National Cancer Institute, vol. 20, issue 1, pp. 80-9, 2008. Abstract

BACKGROUND: Gastric GISTs account for more than half of all gastrointestinal stromal tumors and represent less than 5% of all gastric tumors. The peak age for harboring GIST of the stomach is around 60 years and a slight male preponderance is reported. These tumors are identified by expression of CD117 or CD34 antigen. Symptoms at presentation usually include bleeding, abdominal pain or abdominal mass. Endoscopically, they typically appear as a submucosal mass with or without ulceration and on CT scans an extragastric mass is usually seen. Complete surgical resection provides the only chance for cure, with only 1-2 cm free margins needed. However, local recurrence and/or metastases supervene in almost half the patients treated with surgery alone, even when no gross residual is left. Thereby imatinib mesylate was advocated as an adjuvant to surgery, which appears to have improved disease-free and overall survival.

AIM OF THE WORK: The aim of this work was to assess clinico-pathological features of gastrointestinal stromal tumors (GIST) of the stomach and to appraise the results of treatment by surgery in patients treated at the National Cancer Institute (NCI) of Cairo between January 2002 and December 2007.

PATIENTS AND METHODS: Nineteen patients with histologically and immuno-histochemically proven GIST of the stomach were treated by surgery at the NCI during the 6-year study period. Preoperative assessment included detailed history, clinical examination, full laboratory tests, endoscopy, abdominal ultrasound and CT. General medical assessment included chest X-ray, ECG and echocardiography.

RESULTS: The patients' age ranged from 26 to 77 years with a median of 51 years. Obvious male/female preponderance was noticed (68.4% to 31.6%). Tumors were located at the upper 1/3 in 42.1%, at the middle 1/3 in 31.6% and at the lower 1/3 in 26.3%. The most common clinical presentation was related to bleeding (hematemesis, melena or anaemia) and was seen in 63.2%. No tumors were labeled as very low or low risk while there were 52.6% intermediate risk and 47.4% high risk. Wedge resection was carried out in 15.8%, partial gastrectomy in 37.8%, total gastrectomy in 5.2%, extended gastric resection in 21.1% and only biopsy in 5.2%. Lymphadenectomy was carried out in 5/19 patients to reveal negative lymph nodes in all five. Complications occurred in 73.7% of patients and only 1 case of early postoperative mortality was recorded. Two patients were lost to follow-up. The remaining 16 patients were followed-up for a period ranging from 6-34 months with a mean of 19.5+/-5.6 months and they were all alive by the end of the study, 10 were free of disease and 6 showed disease recurrence.

CONCLUSION: Gastric GIST can present with vague and non specific clinical picture. Therefore, thorough clinical and radiological evaluation and preoperative endoscopy and biopsy are essential to reach the diagnosis and to assess the risk for metastasis. The clinical outcome of these tumors is influenced by completeness of tumor extirpation while avoiding tumor rupture, and by the tumor malignant potential. Accordingly for tumors with adverse factors, multimodal therapy with adjuvant imatinib or one of its successors should be considered in order to improve overall and disease-free survival.

El Marakby, H. H., S. H. E. R. I. F. F. NAGUIB, A. E. - H. F. El-Sawy, and A. A. Amin, "Stepladder reconstructive options in post-ablative complex surgical defects in the head and neck.", Journal of the Egyptian National Cancer Institute, vol. 20, issue 3, pp. 253-61, 2008. Abstract

BACKGROUND: Reconstruction of head and neck defects can pose many challenges to the reconstructive head and neck surgeon. Achieving the best cosmetic and functional results without compromising the safety of oncologic surgery are the primary reconstructive goals. Speech and articulation are particularly important in oral reconstructive procedures. In addition, preservation of the integrity and function of the donor sites should always be considered in all reconstructive procedures.

AIM OF THE STUDY: The aim of the study is to evaluate different reconstructive options in complex defects of the head and neck region after resection of malignant tumours. The feasibility of the reconstructive ladder starting from simple techniques such as local flaps and skin grafts up to free flaps will be assessed.

PATIENTS AND METHODS: In this study we evaluated different reconstructive procedures used in 50 patients with complex head and neck defects undertaken at the department of surgery at the National Cancer Institute between July 2003 and December 2007.

RESULTS: The average age of patients was 52 years and the range was 26-67 years. Most of the tumours were either squamous cell carcinoma (74 %) or Basal cell carcinoma (20 %). Tumour sites included the nose (6 %), lip (10 %), cheek (12 %) scalp (6 %) as well as mucosal defects of the oral cavity (40 %) and the hypopharynx (20 %). We used local flaps and skin grafts in reconstruction in 36 % of cases and pedicled flaps in 32% while free flaps were used in 32 % of cases. Complications occurred in 32 % of patients of which total flaps loss constituted 6 % and partial flap loss 4 %. Minor complications such as oro-cutaneous fistulae, wound infection, seroma and haematoma were noticed in 22 % and all of them were treated conservatively. The final functional and aesthetic results were satisfactory in 60% of cases while poor results were encountered in patients who suffered some degree of flap loss.

KEY WORDS: Head and neck reconstruction - Pedicled flaps - Free flaps.

El-Marakby, H., "Management of early breast cancer with breast conservative surgery. An egyptian experience.", Journal of the Egyptian National Cancer Institute, vol. 21, issue 4, pp. 271-8, 2009. Abstract

BACKGROUND: Breast conservative surgery (BCS) has been an established method for treatment of early breast cancer. The volume of the procedure varies from a wide local excision to partial mastectomy and ipsilateral axillary lymphadenectomy. The nipple and areola complex sparing, depends on their proximity to the tumour. Radiotherapy, chemotherapy and or hormonal treatment play an integral role in the treatment of early breast cancer.

AIM OF THE STUDY: In the present study we present our experience at National Cancer Institute, Cairo University with breast conservative surgery in treatment of female patients with early (T1-T2) breast cancer. The aim is to examine the evidence based management of those cases and the outcome of treatment in terms of loco regional recurrence and/or distant metastasis.

PATIENTS AND METHODS: The study includes 200 with early breast cancer patients who presented to the department of surgery, National Cancer Institute between May 2002 and February 2007. The average age was 46±6.5 years and the range was (26-72 years). Bilateral mammography, chest X-ray and full blood count were done routinely in the entire patients' group. The inclusion criteria included all patients presented with a breast tumor up to 4cm in greatest dimension (T1-2N0).

RESULTS: Sixty Eight percent of patients underwent wide local excision, 20%underwent quadrantectomies, and 12% underwent partial mastectomy with or without nipple and areola preservation. All patients who underwent quadrantectomy or partial mastectomy required an augmentation mammoplasty to restore the breast volume. A latissmus dorsi myocutaneous flap was used in the majority of cases (70%), the rest were reconstructed with either a prosthetic implant or transverse rectus abdominis flap. The complications involved a total flap loss in 2 patients, partial flap loss in 2, nipple and areola sloughing in 4, wound infection in 5, haematoma in 4, seroma in 60, and donor site morbidity in 12 patients. Ninety three percent of patients had a radical radiotherapy treatment (4500G) and 86 percent received adjuvant chemotherapy while only 74% were given hormonal treatment based on the protocol of treatment and the histopathological findings. Late complications in the form of fat necrosis took place in 12% of patients, local recurrence developed in 7% of patients and distant metastasis in 8%, whereas 3% had both local recurrence and distant metastasis.

CONCLUSION: The results of the current study showed that evidence based management of early breast cancer with breast conservative surgery; in terms of the incidence of locoregional recurrence matches favorably with the reported international studies. The present study showed an increased risk of local recurrence in younger patients, patients with high grade disease and those with lymph node metastasis with capsular invasion. Those patients In particular, should be followed up on a regular basis for several years so that any sign of local failure can be diagnosed early and treated accordingly.

KEY WORDS: Breast conservative surgery - Loco regional recurrence - Evidence based management of breast cancer.

El-marakby, H. H., "one stage reconstruction of the oral cavity with an inferior pedicle nasolabial flap", journalof national cancer institute, vol. 53, issue 8, pp. 223-229, 2012.
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