Retroauricular endoscopic thyroidectomy: initial single-institution experiences.

Conventional thyroidectomy often results in visible scarring postoperatively. Endoscopic thyroidectomy offers the advantage of scarless surgery, especially beneficial for young adult women. The retroauricular approach uses a facelift incision well-known among surgeons and eliminates the need for gas insufflation due to the large working space. An early retrospective analysis was conducted on thirty-one individuals who underwent gasless retroauricular endoscopic thyroidectomy approach, focusing on isthmolobectomies (n = 26) and lobectomies (n = 5), with one case necessitating conversion to open thyroidectomy, from January 2016 to April 2017. Physical examination, laboratory, and histopathology findings were collected. The scar was evaluated using the Vancouver Scale System, while other surgical and oncological outcomes were documented and assessed. The average operative time was 154.2 ± 21.3 min, with an average bleeding volume of 69.2 ± 52.1 mL. The average length of stay was 4.7 ± 2.2 days. All complications occurred were temporary and all subjects remained in good condition throughout the follow-up period. Most subjects (65.6%) were very satisfied with the scar concealed in the retroauricular area. Retroauricular endoscopic thyroidectomy is a safe and feasible remote access technique with excellent postoperative results.

The role of HMGCR expression in combination therapy of simvastatin and FAC treated locally advanced breast cancer patients.

OBJECTIVE: Several studies have shown the role of statin added to the patient's chemotherapy regimen and the role of Hydroxymethylglutaryl-CoA Reductase (HMGCR) expression in predicting breast cancer patient outcomes. In our previous study, adding statins improved clinical and pathological responses in LABC patients. Furthermore, we planned to study statin's role as a combination to neoadjuvant chemotherapy (NAC) in treating locally advanced breast cancers on the basis of HMGCR expression. Moreover, we aimed to study the association between the patients' clinicopathological characteristics and HMGCR expression. METHODS: This study is a randomized, double-blinded, placebo-controlled trial in two health centers in Indonesia. Each patient enrolled with written informed consent and then randomized to receive either simvastatin 40 mg/day or a placebo, combined with the fluorouracil, adriamycin, and cyclophosphamide (FAC) NAC. RESULTS: HMGCR was associated with low staging and normal serum cholesterol in the high Ki67 level group (p = 0.042 and p = 0.021, respectively). The pre-and post-chemotherapy tumor sizes are significantly correlated in two groups (HMGCR negative expression, p = 0.000 and HMGCR moderate expression, p = 0.001) with a more considerable average decrease in tumor size compared to HMGCR strong expression group. CONCLUSION: Statin therapy might work better in HMGCR-negative or low-expression tumors, although HGMCR expression is associated with better clinical parameters in our study.

Limb-sparing surgery with latissimus dorsi flap reconstruction in extremity soft tissue sarcoma: Case series.

INTRODUCTION AND IMPORTANCE: Function-preserving and Limb-sparing surgery are now the accepted gold standard of care for Extremity Soft Tissue Sarcoma (ESTS) with the goal of surgery for STS of extremities to obtain local tumor control and minimal morbidity. Limb-sparing surgery with post-operative radiotherapy for STS results in high survival rates and local control. Adjuvant radio chemotherapy might improve distant and local recurrence in high-risk patients. Hence, we aim to present how to achieve local tumor control and minimal morbidity for high grade ESTS by conducting limb-sparing surgery combined with appropriate reconstruction and radio chemotherapy. CASE PRESENTATION: We present 2 cases with high grade sarcoma that underwent limb-sparing surgery with Latissimus Dorsi (LD) flap reconstructions. Wide excisions were completed with limb-sparing surgeries for both cases with free surgical margins and LD flap reconstructions. There was no post-operative complication. Follow up examination revealed normal function of the arm. The first patient was still in remission after 2-years follow up. The second patient got pulmonary metastasis after complete resection and adjuvant radiotherapy. CLINICAL DISCUSSION: Limb-sparing surgery with LD flap reconstruction is able to remove the tumor completely with negative margin for the primary objective. Secondary objectives are minimizing the morbidity, maximizing postoperative body functions, as well as achieving the best cosmetic value are also achieved. LD flap is commonly easy to harvest and able to give large tissue coverage for reconstruction after surgery. CONCLUSION: Limb sparing surgery followed by soft-tissue reconstruction and radio chemotherapy are suitable for increasing oncologic outcome, tumor control, and limb preservation. However, inhibitions towards local recurrence and distant metastases were not guaranteed.

Case series of diagnosis and surgery challenges in parathyroid carcinoma.

INTRODUCTION: Parathyroid carcinoma (PC) is a rare malignancy that accounts for 1 % of cases of hyperparathyroidism. Data regarding PC in Indonesia are scarce, which poses challenges to diagnosis and treatment. This study aims to describe a series of PC cases from a tertiary health care center over 12 years. PRESENTATION OF CASES: Retrospective data of six patients with hyperparathyroidism diagnosed with PC between 2008 and 2020 were reviewed. Clinical presentation, diagnosis, management, and short-term outcomes of PC were analyzed. All six PC patients were diagnosed postoperatively. Four of the patients presented with symptomatic hypercalcemia, and two presented with neck swelling. Elevated serum parathyroid hormone was observed in five patients. Only two patients had imaging results corresponding to PC characteristics. Ipsilateral parathyroidectomies were performed on 5 patients where invasion and metastasis are not evident. Four frozen section samples suggested PC, and two suggested parathyroid adenoma. Further histopathologic examination confirmed a diagnosis of PC in all patients. No metastasis to the adjacent lymph nodes or distant target organs was found during surgery. DISCUSSION: Preoperative diagnosis of PC remains challenging. Suspicion of PC is appropriate in the presence of severe hypercalcemia, elevated parathyroid hormone level, and a mass observed either during imaging or intraoperatively. CONCLUSION: Ipsilateral parathyroidectomy seems to be feasible compared to total resection in order to preserve function and structure. Incomplete excision may lead to an increased risk of recurrence, emphasizing the importance of routinely following up on PC cases.

Comprehensive evaluation on cancer of unknown primary site and how we managed it: A case report.

INTRODUCTION AND IMPORTANCE: Cancer of unknown primary site (CUP) is metastatic cancer without primary tumor found from comprehensive medical history, physical examination, and regular laboratory examination. Eighty percent of CUP include unfavorable groups with 3 to 6 months of median survival despite chemotherapy treatment. CASE PRESENTATION: A 52-year-old male was presented with a chief complaint of a recurrent lump in the neck and axilla. After comprehensive examinations over three years, the primary site of the metastatic tumor could not be found. Therefore, this patient was diagnosed with cancer of an unknown primary site. CLINICAL DISCUSSION: In patient with CUP, more precise therapy can only begin when the exact form of cancer is identified. However, the delay in diagnosis would worsen the patient's condition, as treatment measures cannot be implemented. CONCLUSION: Trimodal modalities including surgery, chemotherapy, and radiotherapy are suitable for CUP with squamous cell carcinoma proven in immunohistochemistry evaluation.

Forequarter amputation post transarterial chemoembolization and radiation in synovial sarcoma: A case report.

INTRODUCTION AND IMPORTANCE: Forequarter amputation or interscapulathoracalis amputation is a major amputation procedure that involves the entire upper extremity, scapula, and a whole or part of the clavicula. Forequarter amputation is commonly used to control bleeding in malignant tumor cases in which no treatment is available for the extremities. CASE PRESENTATION: We report a case of forequarter amputation in a 25-year-old patient with synovial sarcoma. Transarterial chemoembolization (TACE) and radiation synovial sarcoma were performed in the patient to reduce bleeding. This technique may also be used for treating synovial sarcoma with massive bleeding. CLINICAL DISCUSSION: Despite forequarter amputation indications in malignant tumor cases and recurrent cancer cases, the effectiveness of this technique remains unclear. The patient was readmitted with a recurrent mass three months after surgery. CONCLUSION: In this study, TACE and radiotherapy are effective in controlling bleeding preoperatively and intraoperatively in patients with synovial sarcoma.

Combination of Simvastatin and FAC Improves Response to Neoadjuvant Chemotherapy in Locally Advanced Breast Cancer.

PURPOSE: The efficacy of neoadjuvant chemotherapy for locally advanced breast cancer (LABC) is limited due to drug resistance and cardiotoxic effects. Preclinical studies have shown that statin induces apoptosis and decreases breast cancer cell growth. This study aims to evaluate the role of statin in combination with fluorouracil, adriamycin, and cyclophosphamide (FAC) therapy in LABC patients. MATERIALS AND METHODS: We undertook a randomized, double-blinded, placebo-controlled trial in two centers of Indonesia. Patients were randomly assigned to FAC plus simvastatin (40 mg/day orally) or FAC plus placebo (40 mg/day) for 21 days. The FAC regimen was repeated every 3 weeks. We evaluated the clinical response, pathological response, and toxicities. RESULTS: The objective response rate (ORR) for FAC plus simvastatin was 90% (95% confidence interval [CI], 0.99 to 1.67) by per-protocol analysis. No complete responses (CR) were recorded, but there were 48 partial responses. No significant difference was observed between the two groups with the ORR (p=0.103). The pathological CR rate was 6.25% (2 in simvastatin group and 1 in placebo group). Adverse events in both arms were generally mild, mainly consisted of myotoxicity. Human epidermal growth factor receptor 2 (HER2) expression was a factor related to the success of therapeutic response (odds ratio, 4.2; 95% CI, 1.121 to 15.731; p=0.033). CONCLUSION: This study suggests that simvastatin combined with FAC shows improvements in ORR and pathological response in patients with LABC. Although no statistically significant difference was documented, there was a trend for better activity and tolerability. The addition of 40 mg simvastatin may improve the efficacy of FAC in LABC patients with HER2 overexpression.

Endoscopic thyroidectomy via axillary-breast-shoulder approach: Early experience of 42 cases.

BACKGROUND: Most patients in Indonesia present with large-sized thyroid nodules, which need surgical removal to exclude malignancy. Many surgeons prefer endoscopic thyroidectomy to avoid a large and visible surgical scar on the neck and to reduce postoperative complications. This study aims to evaluate and analyze surgical feasibility, safety, oncologic outcome, and patient satisfaction of endoscopic thyroidectomy via the axillary-breast-shoulder approach. METHODS: Between August 2010 and September 2015, 42 endoscopic thyroidectomies via the axillary-breast-shoulder approach with carbon dioxide insufflation up to 8-10 mmHg were performed and retrospectively reviewed. RESULTS: Mean tumor size and operative time were 3.11 ± 0.99 cm and 189 ± 45 min, respectively. Mean blood loss was 68.3 mL. There were temporary complications such as hoarseness (19%), emphysema (2.3%) and hematoma (2.3%). Mean hospital length of stay was 3.98 days. Most subjects (61.9%) were very satisfied with the postoperative scar. The visual analog score of postoperative pain decreased from 4.83 on day-1 to 2.28 on day-7. The tumor recurrence was 9.6%. CONCLUSIONS: Endoscopic thyroidectomy via the axillary-breast-shoulder approach is feasible, safe, and minimally invasive with excellent postoperative results.

Diagnostic Approach for Thyroid Nodules.

Thyroid nodule is a health problem which commonly found in daily practice, therefore clinical guidance is needed. This guideline was compiled by a multidisciplinary team and expected to be a guideline in diagnosing thyroid nodules on daily clinical practice.

Surgical perspective of T1799A BRAF mutation diagnostic value in papillary thyroid carcinoma.

BACKGROUND: Throughout Indonesia, thyroid cancer is one of the ten commonest malignancies, with papillary thyroid carcinoma (PTC) in our hospital accounting for about 60% of all thyroid nodules. Although fine needle aspiration biopsy (FNAB) is the most reliable diagnostic tool, some nodules are diagnosed as indeterminate and second surgery is common for PTC. The aim of this study was to establish the diagnostic value and feasibility of testing the BRAF T1799A mutation on FNA specimens for improving PTC diagnosis. MATERIALS AND METHODS: This prospective study enrolled 95 patients with thyroid nodules and future surgery planned. Results of mutational status were compared with surgical pathology diagnosis. RESULTS: Of the 70 cases included in the final analysis, 62.8% were PTC and the prevalence of BRAF mutation was 38.6%. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for BRAF mutation analysis were 36%, 100%, 100% and 48%, respectively. With other data findings, nodules with "onset less than 5 year" and "hard consistency" were proven as diagnostic determinants for BRAF mutation with a probability of 62.5%. This mutation was also a significant risk factor for extra-capsular extension. CONCLUSIONS: Molecular analysis of the BRAF T1799A mutation in FNAB specimens has high specificity and positive predictive value for PTC. It could be used in the selective patients with clinical characteristics to facilitate PTC diagnosis and for guidance regarding extent of thyroidectomy.