Modulating the extension of axillary lymphadenectomy for early stage breast cancer.

Axillary lymph node evaluation remains essential in breast cancer surgery, first as a prognostic factor, because it indicates the degree of dissemination of the disease to the main lymphatic drainage basin of the breast, and, on the other hand, as an element of preventing the local relapse. In the era of the sentinel lymph node, complete axillary lymphadenectomy, considered valuable until recently, but as therapeutic and diagnostic, has become an intervention performed increasingly rare in selected cases. Axillary lymphatic tissue resections are accompanied by morbidity (lymphedema, paresthesia, limitations of arm movement) and symptom magnitude is proportional to the extension of the intervention. For this reason, a solution to avoid these kinds of complications was looked for. Since Gould, in 1960, who mentioned cancer parotid and continuing with Cabanas, Morton, or Veronesi, many surgeons have contributed to the development of safe techniques with which the multidisciplinary team involved in the surgical treatment for breast cancer could perform a safe oncological intervention and at the same time could conserve the healthy tissue, thus limiting morbidity. To achieve this standard, axillary lymphadenectomy has passed through several stages, from over radical interventions that followed the Halsted era, in which, besides axillary lymph nodes, the internal mammary and jugulo-carotidian lymph nodes were excised, to the absence of axillary surgery and replacing it with radiation therapy.

Evolution of radical mastectomy for breast cancer.

Surgical treatment of breast cancer has been marked by a constant evolution since the Halsted radical mastectomy described in the late 19th century has become the current standard Madden radical mastectomy, a breast surgery that involves the ablation of tissue with the axillary lymphatic preserving both pectoral muscles. The purpose of this paper was to present the stages that have marked the evolution of this intervention and to provide an overview of the way breast cancer has been understood and treated in the last century.

Types of radical hysterectomies : From Thoma Ionescu and Wertheim to present day.

The treatment for cervical cancer is a complex, multidisciplinary issue, which applies according to the stage of the disease. The surgical elective treatment of cervical cancer is represented by the radical abdominal hysterectomy. In time, many surgeons perfected this surgical technique; the ones who stood up for this idea were Thoma Ionescu and Ernst Wertheim. There are many varieties of radical hysterectomies performed by using the abdominal method and some of them through vaginal and mixed way. Each method employed has advantages and disadvantages. At present, there are three classifications of radical hysterectomies which are used for the simplification of the surgical protocols: Piver-Rutledge-Smith classification which is the oldest, GCG-EORTC classification and Querlow and Morrow classification. The last is the most evolved and recent classification; its techniques can be adapted for conservative operations and for different types of surgical approaches: abdominal, vaginal, laparoscopic or robotic.

Postoperative surgical complications of lymphadenohysterocolpectomy.

UNLABELLED: Rationale The current standard surgical treatment for the cervix and uterine cancer is the radical hysterectomy (lymphadenohysterocolpectomy). This has the risk of intraoperative accidents and postoperative associated morbidity. Objective The purpose of this article is the evaluation and quantification of the associated complications in comparison to the postoperative morbidity which resulted after different types of radical hysterectomy. METHODS AND RESULTS PATIENTS WERE DIVIDED ACCORDING TO THE TYPE OF SURGERY PERFORMED AS FOLLOWS: for cervical cancer - group A- 37 classic radical hysterectomies Class III Piver - Rutledge -Smith ( PRS ), group B -208 modified radical hysterectomies Class II PRS and for uterine cancer- group C -79 extended hysterectomies with pelvic lymphadenectomy from which 17 patients with paraaortic lymphnode biopsy . All patients performed preoperative radiotherapy and 88 of them associated radiosensitization. Discussion Early complications were intra-abdominal bleeding ( 2.7% Class III PRS vs 0.48% Class II PRS), supra-aponeurotic hematoma ( 5.4% III vs 2.4% II) , dynamic ileus (2.7% III vs 0.96% II) and uro - genital fistulas (5.4% III vs 0.96% II).The late complications were the bladder dysfunction (21.6% III vs 16.35% II) , lower limb lymphedema (13.5% III vs 11.5% II), urethral strictures (10.8% III vs 4.8% II) , incisional hernias ( 8.1% III vs 7.2% II), persistent pelvic pain (18.91% III vs 7.7% II), bowel obstruction (5.4% III vs 1.4% II) and deterioration of sexual function (83.3% III vs 53.8% II). PRS class II radical hysterectomy is associated with fewer complications than PRS class III radical hysterectomy , except for the complications of lymphadenectomy . A new method that might reduce these complications is a selective lymphadenectomy represented by sentinel node biopsy . In conclusion PRS class II radical hysterectomy associated with neoadjuvant radiotherapy is a therapeutic option for the incipient stages of cervical cancer. ABBREVIATIONS: PRS- Piver Rutledge-Smith, II- class II, III- class III.

Occult breast lesion localization and concomitant sentinel lymph node biopsy in early breast cancer (SNOLL).

AIMS: Mammographic screening and the increasing resolution output of mammography have raised the identification number of small-size mammary lesions without clinical expression. The aim of this study was to evaluate in a prospective study the localization techique and concomitent sentinel lymph node biopsy for breast cancer (SNOLL - Sentinel lymph Node biopsy and Occult Lesion Localization). METHODS: We identified by means of imaging techniques a number of 107 patients with clinically occult suspicious breast tumors. All patients preoperatively underwent a protocol in which the injection of 99mTc-nannocolloid under imaging procedures was performed. Surgical excision was performed, guided by the hand held gammaprobe. The sentinel lymph node was identified as an axillary hot spot on the probe. RESULTS: All primary lesions were identified and were clear of invasive margins needing excision. 98 tumors proved to be malignant on frozen sections. 7 lesions could not be clearly examined through frozen section and 2 proved to be benign. 6 out of 7 suspicious lesions confirmed to be malignant on parrafin embedded sections. Sentinel lymph node was identified in a number of 95 out of 98 patients. In 14 cases complete axillary lymphadenectomy was performed. The average specimen weight was 40 grams. CONCLUSIONS: Using this technique, we removed the lesions identified prior to surgery in all cases, achieving a complete pathologic diagnostic, the necessary surgical treatment and also prognostic data by axillary lymph node assessment.

Immunological aspects predicting metastatic sentinel lymph node in early breast cancer patients.

Tumour antigens are poorly expressed, heterogeneous and they modulate rapidly. As a result, their recognition and elimination by the immune system is very difficult. There are several mechanisms, by means of which, the host can neutralize oncogenesis and prevent it from occurring. The sentinel lymph node concept has brought about a revolution in the surgical treatment of the regional lymphatic basin while preserving the prognostic value of the regional lymph node status in breast cancer. This prospective study included 93 women with early breast cancer with initial indication for surgery in whom the sentinel lymph node technique was employed. Cell immune response was assessed prior to surgery by means of in vitro mononuclear cells blastic transformation assay (BLT), of immunoglobulin (Ig) and interleukin 2 (IL-2) measurements. The results were correlated with tumour size, presence of positive sentinel lymph node, tumour proliferation and growth markers (Ki-67, c-erbB2, bcl-2). Even in its less advanced stages, breast cancer is more aggressive and associates with an increased rate of sentinel lymph node metastases in patients below 50 years old, the tumour size exceeds 20 mm, with the presence of peritumoral lymphocytic infiltrate, positive Ki-67 and bcl-2, an alteration of T helper (Th) lymphocytes function, increased immune suppression through IL-2 decrease, signalled by blastic transformation indexes modifications and a drop in IL-2 production (p<0.01).