The role of intraoperative frozen section of central neck lymph nodes in the management of patients preoperatively diagnosed with low- risk differentiated cancer.

INTRODUCTION: Histological examination during surgery (FS) has a place in the surgical management of differentiated thyroid carcinoma (DTC). Extending the indication for limited surgery to 4 cm tumor size (ATA guidelines 2015) cytologically verified DTCs, increases the emphasis on accurate patient selection. In our work, we reflected on the effectiveness of FS and its relationship to optimal patient management. METHODS: In a single-center retrospective study, we evaluated the documentation of patients indicated for primary surgery for DTC from January 1, 2016 to December 31, 2020 - there was 489 patients collectively, 121 were men, median age was 50 years (1681), 73 patients (female, age 1845 years) with preoperatively identified low-risk DTC (size 1140mm) were indicated for lobectomy. RESULTS: 34 patients (46.6%) did not meet the criteria for limited surgery 15 patients were identified from FS of the lymph nodes of the central compartment (LNCK) (15 of 25 patients) - 1 patient with false negative result and 6 patients with FS of the thyroid gland (SH) (6 / 41) - 11 patients with false negative findings. Two-step OP surgery was performed on 13 patients (17.8%). FS of LNCK identified high-risk cancer and reduced the risk of two-step surgery compared to the group of patients in whom FS was not performed or was performed from thyroid gland. The difference was statistically significant (OR 1.93, p=0.026). CONCLUSION: Approximately ½ of the patients from preoperatively identified low-risk cancers in our cohort met the criteria for limited surgery. About 30% of them eventually needed a two-step operation. Perioperative examination of LNCK helps to perform radical surgery at one time.

Postoperative pancreatic fistula after pancreatic resection.

BACKGROUND: The failure of pancreatic anastomosis after the proximal pancreaticoduodenectomy (PD) and the failure of pancreatic stump after the distal pancreatectomy with a resulting postoperative pancreatic fistula remain the most feared complications after pancreatic resection. Surgeons have been trying to find a reliable reconstructive technique of pancreatic anastomosis for decades. METHODS: A literature search was performed to January 2020. Studies giving a detailed description of the pancreatic anastomosis after open PD and pancreatic stump closure techniques after the distal pancreatectomy were included. The aim of this study was review reported data derived from meta-analyses concerning the incidence of POPF according to the International Study Group of Pancreatic Surgery. A comparison of various surgical techniques and their impact on POPF incidence was made. RESULTS: In the group of clinically relevant POPF (CR- POPF), a well established difference between the patients undergoing POPF-associated interventional drainage or reoperation was observed. Meta-analyses showed that the patients with CR- POPF were statistically more likely to have a small duct size, soft gland texture, particular pancreatic neoplasms and an excessive intraoperative blood loss. CONCLUSION: Grade C POPF following PD, although uncommon, occurs with a defined incidence and is associated with a substantial morbidity, prolonged hospitalization, delayed recovery and a significant mortality. According to the results of various meta-analyses, pancreatogastrostomy and pancreatojejunostomy seemed to be comparable anastomotic techniques following PD (Ref. 54).

Ampullary cancer in a patient with familial adenomatous polyposis - a rare case report and current status of management.

Familial adenomatous polyposis (FAP) is an inherited autosomal dominant disorder. Extracolonic manifestations are seen quite often. As prophylactic colectomy has become a standard care in FAP patients, the concerns over the development of associated extracolonic malignancies have become more prevalent. The authors report a case of a patient with the history of subtotal colectomy because of FAP with the development of adenocarcinoma of papilla of Vater twenty-six years later. A radical procedure in form of proximal pancreaticoduodenectomy was indicated. Variable endoscopic surveillance protocols and treatment strategies have been proposed concerning the management of duodenal and periampullary lesions. In case of periampullary malignancies, the radical surgical resection offers the only chance for cure and the only option that may safeguard the long­term survival (Fig. 2, Ref. 30). Keywords: ampulla of Vater, bile duct, obstructive jaundice, pancreatoduodenectomy, periampullary tumors.

Recurrence after sentinel lymph node biopsy in cutaneous melanoma: a single-center experience in Slovak patients.

The standard approach in the management of cutaneous malignant melanoma is considered to be a complete excision of the primary lesion with an appropriate margin of the normal tissue according to Breslow thickness. Usually sentinel lymph node biopsy (SLNB) can help to determine the nodal status, and thus improve the accuracy of staging of the disease. However, the role of SLNB in melanoma treatment remains controversial. NCCN guidelines strongly support routine performance of therapeutic lymphadenectomy in all melanoma patients with clinically positive nodes without radiographic evidence of distant metastases. Patients with positive SLNB should have had completion lymph node dissection (CLND) for regional disease control. Between 2012 and 2016, 168 consecutive patients underwent surgery for primary cutaneous malignant melanoma at St. Elisabeth Cancer Institute in Bratislava. The indication for SLNB and the procedure was made according to international guidelines. In this retrospective study, a cohort of 78 patients was analyzed (35 women and 43 men). Inclusion criteria comprised patients with cutaneous melanoma with no evidence of distant metastases or clinical lymphadenopathy. SLNB comprised a dual labelling method (Tc-99m Nanocolloid / blue dye) in a one-day protocol. Median follow-up was 657 days. The primary composite outcome was the time to the first disease-related event (death, reintervention, worsening of symptoms). Primary outcome measures were overall (disease-specific) and disease-free survival. The overall identification rate of SLN in melanoma patients by dual labelling method was 98.5%. All patients with positive SLNB on frozen section underwent complete regional lymphadenectomy. Using multivariable analysis Breslow thickness of the lesion (p=0.00004, HR 4.03 on logarithmic scale) was identified as the strongest independent predictor of the disease-free survival (DFS) and male gender was significant predictor of DFS. An increase in tumor thickness was associated with significantly higher risk of an event. Neither SLN positivity nor initial S-100 level proved to be significant predictors of the event at the 0.05 level of probability. Multidisciplinary approach represents the gold standard of care for melanoma patients and surgery remains the best option for most localized cases. Although the usefulness of SLNB procedure has been questioned, it provides an excellent staging method, moreover, it can identify high-risk patients. The routine use of completion lymphadenectomy after a positive SLNB is still controversial. It is not clear whether CLND following a positive SLN biopsy improves survival but it could provide regional disease control.