Breast cancer electron intraoperative radiotherapy: assessment of preoperative selection factors from a retrospective analysis of 758 patients and review of literature.

PURPOSE: To report our experience with full-dose 21 Gy IORT in early breast cancer patients after breast-conserving surgery to define most important selection factors. METHODS: Seven hundred and fifty eight patients, subjected to conserving surgery and IORT, were retrospectively analyzed evaluating most important clinical outcomes. RESULTS: Median follow up was 5.2 years. Results from Cox analyses defined 2 groups of patients, "suitable" (age > 50 years, non lobular histology, tumour size ≤ 2 cm, pN0 or pNmic, ki67 ≤ 20%, non triple negative receptor status and G1-G2) and "unsuitable" for IORT, with a higher rate of breast related events moving from "suitable" to "unsuitable" group. The 5 year rate of IBR is 1.8% in suitable group with significant differences versus unsuitable (1.8 vs. 11.6%, p < 0.005). Same differences between two groups were evidenced in true local relapse (0.6 vs. 6.9%, p < 0.005) and in new ipsilateral BC (1.1 vs. 4.7%, p < 0.015). CONCLUSIONS: In our current practice we consider the following preoperative factors to select patients suitable for IORT: age > 50 years, absence of lobular histology, tumor size ≤ 2 cm, pN0 or pNmic, according to APBI consensus statement, including also ki67 ≤ 20%, non triple negative receptor status and G1-G2.

Breast-conservative surgery with and without radiotherapy in patients aged 55-75 years with early-stage breast cancer: a prospective, randomized, multicenter trial analysis after 108 months of median follow-up.

OBJECTIVES: Breast-conserving therapy (BCT), including postoperative whole breast irradiation (WBI), is generally accepted as the treatment of choice for most patients with early-stage breast cancer. The question whether WBI is mandatory in all patients remains one of the most controversial issues in BCT. To answer this question, a randomized, prospective, multicentre study was launched in January 2001. Primary endpoints of the study were to assess the cumulative incidence of in-breast-recurrences (IBR) and overall survival (OAS) after conservative surgery (BCS) with or without WBI. METHODS: From January 2001 until December 2005, 749 patients with unifocal infiltrating breast cancer up to 25 mm, 0-3 positive axillary lymph nodes, no extensive intraductal component or lymphvascular invasion from 11 centres in Italy, were randomly assigned to BCS+WBI (arm 1:373 patients) or BCS alone (arm 2:376 patients). Treatment arms were well balanced in terms of baseline characteristics. Systemic adjuvant therapy was administered according to the institutional policies. Kaplan-Meier method was used for survival analysis and log-rank test to evaluate the difference between the two arms. RESULTS (Last analysis 31.12.2012): After median follow-up of 108 months, 12 (3.4%) IBR were observed in arm 1 and 16 (4.4%) in arm 2. OAS was 81.4% in arm 1 and 83.7% in arm 2. There was no statistically significant difference regarding IBR and death in the two treatment groups. CONCLUSIONS: These data are promising and suggest that WBI after BCS can be omitted in selected patients with early stage breast cancer without exposing them to an increased risk of local recurrence and death. Longer follow-up is needed to further consolidate these results.

Conservative surgery with and without radiotherapy in elderly patients with early-stage breast cancer: a prospective randomised multicentre trial.

Breast conserving therapy (BCT) including postoperative irradiation of the remaining breast tissue is generally accepted as the best treatment for the majority of patients with early-stage breast cancer. The question is whether there is a necessity for irradiating all patients. Between 2001 and 2005, 749 women aged 55-75 years with infiltrating breast carcinoma were randomly assigned to breast conservative surgery, with or without radiotherapy (RT), to evaluate the incidence of in-breast recurrence (IBR). After 5 years of median follow-up, the cumulative incidence of IBR was 2.5% in the surgery-only arm and 0.7% in the surgery plus RT arm. There are no differences in terms of overall survival and distant disease-free survival. The preliminary evaluation suggests that breast irradiation after conservative surgery can be avoided without exposing these patients to an increased risk of distant-disease recurrence. Prolonged follow-up will further clarify the possible risks and late sequelae potentially induced by breast RT.

Axillary recurrence in sentinel lymph node-negative breast cancer patients.

BACKGROUND: Sentinel lymph node biopsy (SLNB) was developed to axillary lymph node dissection (ALND) in the treatment of breast cancer. SLNB is predictive of axillary node status. Major concern is the occurrence of a false-negative SLN. Purpose of this study is to determine the rate of axillary recurrence in our series of unselected patients. PATIENTS AND METHODS: All patients with a negative SLNB from November 1999 to December 2006 have been treated and followed at our unit. Information on patients' characteristics, treatment and follow-up has been collected. RESULTS: Eight-hundred and four patients with negative SLNB did not receive ALND. After a median follow-up of 38.8 months, 21 patients had distant metastases, four had axillary relapse, nine had an in-breast recurrence and two had both. All patients with axillary recurrence received axillary dissection and systemic adjuvant therapy. They are all presently alive and free from disease. CONCLUSION: Data from this series, the largest from a general hospital, showed that isolated axillary node recurrence after negative SLNB is rare (<1%) and comparable with those reported from referral cancer institutions. We confirm that SLNB for the treatment of early breast cancer patients of a community-based hospital is safe and reliable.

Population-based sentinel lymph node biopsy in early invasive breast cancer.

INTRODUCTION: Sentinel lymph node biopsy (SLNB) has been proposed as a reliable method for staging of early invasive breast cancer (EIBC). In the present study we analyse the impact of this procedure when systematically applied to all unselected women of a community-based Breast Cancer Unit (BCU). METHODS: All consecutive women with unifocal cT1-2 (

Sentinel node biopsy in the surgical management of breast cancer: experience in a general hospital with a dedicated surgical team.

The aims of this study were to analyse the feasibility and accuracy of the sentinel lymph node biopsy (SLNB) procedure as performed in a general hospital compared with the literature results; to report on the organizational aspects of planning surgical time with higher accuracy of pathological analysis; and to verify that there is a real advantage of SLNB in the surgical management of breast cancer. From October 1999 to September 2000, 371 consecutive patients with T1-2N0 breast lesions underwent SLNB. The immunoscintigraphic method of sentinel node identification was the main one used, the blue dye method being used only when the lymphoscintigraphic method was unsuccessful in identifying sentinel nodes. SLNB was done under either general or local anaesthesia, depending on how the surgical procedure was organized and clinically planned. SLNB was successful in 99% of these T1-2N0 breast cancer cases, and in 71% no metastases were found in the sentinel node. In 47% of cases with axillary metastasis only the sentinel node was involved. Nodal involvement was not present in any case of microinvasive or in situ carcinoma. In T1 cancers nodal involvement was present in 21%; in T2 cases the corresponding rate reached 51%. The results obtained with the SLNB procedure at Bergamo Hospital are similar to the literature data. When a dedicated surgical team, the nuclear medicine department and the pathology department work together, a general hospital can provide breast cancer patients with appropriate surgical treatment.

[Digestive hemorrhage secondary to fistula between hepatic artery and jejunal stump following duodenocephalopancreasectomy. A clinical case]. / Emorragia digestiva secondaria a fistola tra arteria epatica e moncone digiunale in esiti di duodenocefalopancreasectomia. Caso clinico.

The authors describe a case of one patient who underwent duodenocephalopancreasectomy for CBD cancer 6 years ago and developed gastrointestinal bleeding caused by a fistula between the hepatic artery and the jejunal stump. They discuss the differential diagnosis problem in the gastrointestinal bleeding syndrome caused by this rare pathology.

[Surgical treatment of liver trauma: our experience]. / Il trattamento chirurgico dei traumi epatici: nostra esperienza.

The Authors report their ten-year experience in the surgical treatment of liver injuries. Thirty-five patients underwent emergency laparotomy for hepatic trauma: 14 showed associated injuries, mostly of the spleen, while 21 had isolated liver lesions. Emergency surgical operation was performed for those patients with hypovolemic shock due to massive haemoperitoneum, while for all stabilized patients a preoperative ultrasonography or a computerized tomography was diagnostic. With a correct diagnosis, nowadays possible thanks to the overmentioned radiologic means, a group of patients was not treated by laparotomy, but strictly monitorized. For the patients who underwent laparotomy, good results with a low mortality rate were obtained using a surgical conservative treatment.

[Surgical treatment of major obesity by biliopancreatic bypass: our experience]. / La thérapie chirurgicale de la grande obésité par by-pass biblio-pancréatique: notre expérience.

The Authors report their experience in the surgical management of morbid obesity. The efficacy of the bilio-pancreatic by-pass, method created by Nicola Scopinaro in the 1976, is underlined. From November 1988, 41 patients affected by morbid obesity were treated with this method. Results obtained are comparable to those reported in literature, with important weight loss and decrease of the cardiovascular risk-factors.

[The surgical therapy of morbid obesity: our experience]. / Terapia chirurgica della grande obesità: la nostra esperienza.

The authors report their experience of two years in the surgical management of morbid obesity. The efficacy of the biliopancreatic diversion, method created by Nicola Scopinaro, is underlined. Sixteen patients affected by morbid obesity were treated with this method. Results obtained are comparable to those reported in literature; therefore the authors have been induced to continue in this direction.

Consulting in the 90's--boardroom to bedside.

Much like the healthcare industry, the consulting industry is in a period of great change. The traditional services that once were the mainstay of consulting are giving way to broader, more strategic services. New consulting firms are emerging; others are consolidating. The best firms are those that are growing and changing along with the clients they service in order to meet the variety of needs in today's complex, competitive environment.

[Surgical treatment of pheochromocytoma: our experience]. / Terapia chirurgica del feocromocitoma: la nostra esperienza.

The Authors report their experience of pheochromocytoma surgical treatment based on four recent cases one of which with extra-adrenal location. Newest and more refined diagnostic techniques as well as modern pathophysiologic data allow an early detection of the disease. Furthermore, the availability of proper medico-surgical therapeutic modalities assures less risks and better results.

[Leiomyoblastoma of the small intestine]. / Il leiomioblastoma del tenue.

A case of leiomyoblastoma in the small intestine is illustrated. The patient underwent first and iliac resection and then, 36 months later, a removal of multiple hepatic metastasis. The authors recall as the benign appearance of a leiomyoblastoma sometimes in only apparent, so that it's quite difficult predicting its evolution. Not any histological method can give express an available valuation about the neoplasm malignant potency.

Product-line performance reporting: a key to cost management.

For many hospitals, performance reporting is the most important and valuable function of a cost management system. Performance reporting provides hospitals--or any organization, for that matter--with an enhanced ability to reduce and control costs and monitor profitability. By periodically comparing strategic and operational plans with actual results, managers are provided with measurements of their performance for the aspects of the organization they control. The following is an excerpt from the book, Cost Management for Hospitals. This section deals with product-line performance reporting and the variances that measure the effects different factors have on performance.