Fluorescence Imaging in Colorectal Surgery: An Updated Review and Future Trends.

Fluorescence imaging in colorectal surgery is considered a novel predominantly intraoperative method of ensuring a greater surgical success. The use of fluorescence is linked to advanced tumor visualization and projection of its lymphatics, both vessels and nodes, which results in a higher chance of achieving a total excision. Additionally, iatrogenic complications prove to be reduced using fluorescence during the surgical excision. The combination of fluorescence and artificial intelligence to better facilitate oncological surgery will soon become an established approach in operating rooms worldwide.

Fluorescence Imaging Using Methylene Blue Sentinel Lymph Node Biopsy in Melanoma.

INTRODUCTION: Fluorescence imaging of sentinel node biopsy in melanoma is a novel method. Both indocyanine green (ICG) and methylene blue (MB) have fluorescent properties. The aim of this study was to present, for the first time in a clinical series of patients, the possible usage of MB as a fluorescent dye for sentinel node biopsy during surgery for melanoma. MATERIAL AND METHODS: Twenty patients with skin melanoma, who were candidates for sentinel node biopsy were enrolled in our study. All patients underwent simultaneous use of standard nanocolloid and blue dye. Transcutaneous visualization of the sentinel node, visualization of lymphatic channels as well as sentinel node fluorescent visualization were all measured. We also performed calculations of Signal to Background ratios (SBR). RESULTS: In 15% (3/20) of patients, the fluorescent sentinel node was visible through the skin. The median SBR for the sentinel node visualization by fluorescence was 3.15 (range, 2.7-3.5). Lymphatic channels were visible in lymphatic tissue via fluorescence before visualization by the naked eye in 4 patients (20%). The median SBR ratio was 3.69 (range, 2.7-4.2). Sentinel nodes were visible by fluorescence in 13 cases (65%). The median SBR ratio was 2.49 (range, 1.5-5.7). No factors were found to be associated with fluorescent MB visualization of a sentinel node during biopsy. CONCLUSION: This is the first clinical study presenting the usefulness of fluorescent sentinel node biopsy in melanoma patients using MB as a fluorophore. Further studies are necessary to provide methods for its' clinical implementation.

Multispectral Imaging Using Fluorescent Properties of Indocyanine Green and Methylene Blue in Colorectal Surgery-Initial Experience.

Introduction: Image-guided surgery is becoming a new tool in colorectal surgery. Intraoperative visualisation of different structures using fluorophores helps during various steps of operations. In our report, we used two fluorophores-indocyanine green (ICG), and methylene blue (MB)-during different steps of colorectal surgery, using one camera system for two separate near-infrared wavelengths. Material and methods: Twelve patients who underwent complex open or laparoscopic colorectal surgeries were enrolled. Intravenous injections of MB and ICG at different time points were administered. Visualisation of intraoperative ureter position and fluorescent angiography for optimal anastomosis was performed. A retrospective analysis of patients treated in our departments during 2020 was performed, and data about ureter injury and anastomotic site complications were collected. Results: Intraoperative localisation of ureters with MB under fluorescent light was possible in 11 patients. The mean signal-to-background ratio was 1.58 ± 0.71. Fluorescent angiography before performing anastomosis using ICG was successful in all 12 patients, and none required a change in position of the planned colon resection for anastomosis. The median signal-to-background ratios was 1.25 (IQR: 1.22-1.89). Across both centres, iatrogenic injury of the ureter was found in 0.4% of cases, and complications associated with anastomosis was found in 5.5% of cases. Conclusions: Our study showed a substantial opportunity for using two different fluorophores in colorectal surgery, whereby the visualisation of one will not change the possible quantification analysis of the other. Using two separate dyes during one procedure may help in optimisation of the fluorescent properties of both dyes when using them for different applications. Visualisation of different structures by different fluorophores seems to be the future of image-guided surgery, and shows progress in optical technologies used in image-guided surgery.

Comparison of claudin-3 and claudin-4 expression in bilateral and unilateral breast cancer.

Claudins are essential components of tight junctions, which are frequently deregulated in breast cancer. The aim of the current study was to assess claudin-3 and -4 expression in bilateral breast cancer (BBC) and unilateral breast cancer (UBC). Immunohistochemical expression of claudin-3 and claudin-4 was evaluated in tissue microarrays containing 174 cases of BBCs paired with 174 cases of solitary tumors. Each case was classified as claudin-high or claudin-low depending on the H-score value. The results were correlated with histopathological features and the expression of basic breast cancer biomarkers. Median H-scores for claudin-3 were significantly higher in the synchronous BBC (sBBC) than in UBC. Claudin-4-high cases were more prevalent than within the whole BBC group, and sBBC and metachronous BBC (mBBC) alone. In the BBC group negative ER, high Ki-67 and high claudin-3 were independent factors correlated with high claudin-4. In the UBC group, Ki-67 >14% and high claudin-3 were associated with high claudin-4. Our study demonstrates that the expression of claudin-4 is significantly higher in UBC compared to BBC tumors. We also demonstrated that high claudin-4 expression in BBC is associated with a more aggressive phenotype (lack of steroid receptors, HER2 overexpression, and high Ki-67). It is possible that claudins down- and upregulation may depend on different triggers and lead to various consequences in UBC and BBC.

Influence of malnutrition stage according to GLIM 2019 criteria and SGA on the quality of life of patients with advanced cancer.

INTRODUCTION: Introduction: the nutritional status of cancer patients should be screened regularly due to their high risk of malnutrition, which impairs patient quality of life (QoL). Therefore, an assessment of nutritional status is strongly necessary. Recently, the Global Leadership Initiative on Malnutrition (GLIM) criteria for assessing the severity of malnutrition were published (2019). Objectives: the primary aim of this study was the assessment of nutritional status and QoL in advanced cancer patients. A secondary aim was to investigate the impact of malnutrition severity on QoL in these patients. Methods: this study included 33 advanced cancer patients (head/neck, esophageal, gastric) from the Nutritional Counselling Centre Copernicus in Gdansk, and the Department of Surgical Oncology, Medical University of Gdansk, Poland. The assessment of nutritional status was conducted with the 2019 GLIM criteria and the Subjective Global Assessment (SGA) method. QoL was assessed using the World Health Organization Quality of Life-BREF questionnaire (WHOQOL-BREF). Results: according to the SGA method, most of the patients were malnourished (42.42 %) or severely malnourished (42.42 %). Based on the GLIM criteria, 69.7 % of patients (n = 23) were severely malnourished. Among all participants, the highest impairments of QoL were observed in the environmental and psychological domains of the self-assessed satisfaction with own health questionnaire. Severe malnutrition significantly impairs QoL in the psychological (GLIM stage 2, p = 0.0033; SGA C, p = 0.0310) and somatic domains (GLIM stage 2, p = 0.0423). Conclusions: most patients with advanced cancer are malnourished or severely malnourished. Overall, the QoL of these patients is impaired. The severity of malnutrition has an impact on the QoL of cancer patients, which is observed as an impairment of mainly psychological and somatic aspects. This is the first study assessing the impact of malnutrition severity, as based on the new 2019 GLIM criteria, on the QoL of advanced cancer patients.

INTRODUCCIÓN: Introducción: el estado nutricional de los pacientes con cáncer debe examinarse regularmente debido al alto riesgo de desnutrición, lo que perjudica la calidad de vida (QoL) de los pacientes. Por lo tanto, la evaluación del estado nutricional es muy necesaria. Recientemente se han publicado los criterios de la Iniciativa de Liderazgo Global sobre Desnutrición (GLIM) de 2019, que evalúan la gravedad de la desnutrición. Objetivos: los objetivos principales de este estudio fueron la evaluación del estado nutricional y la calidad de vida de los pacientes con cáncer avanzado. El objetivo secundario fue investigar el impacto de la gravedad de la desnutrición en la calidad de vida de estos pacientes. Métodos: este estudio incluyó a 33 pacientes con cáncer avanzado de cabeza/cuello, esófago y gástrico del Centro de Asesoría Nutricional Copernicus de Gdansk y el Departamento de Oncología Quirúrgica de la Universidad de Medicina de Gdansk, Polonia. La evaluación del estado nutricional se realizó con los criterios GLIM 2019 y el método de evaluación subjetiva global (SGA). La calidad de vida se evaluó mediante el cuestionario Quality of Life-BREF de la Organización Mundial de la Salud (WHOQOL-BREF). Resultados: según el método SGA, la mayoría de los pacientes estaban desnutridos (42,42 %) o gravemente desnutridos (42,42 %). Según los criterios GLIM, el 69,7 % de los pacientes (n = 23) estaban gravemente desnutridos. Entre todos los participantes se observó un mayor deterioro de la calidad de vida en la autoevaluación de la satisfacción con la salud, en los dominios ambiental y psicológico. La desnutrición severa afecta significativamente a la calidad de vida en el dominio psicológico (etapa GLIM 2, p = 0,0033; SGA C, p = 0,0310) y somático (etapa GLIM 2, p = 0,0423). Conclusiones: la mayoría de los pacientes con cáncer avanzado están desnutridos o gravemente desnutridos. En general, la calidad de vida de estos pacientes está alterada. La gravedad de la desnutrición repercute sobre la calidad de vida de los pacientes con cáncer, lo que se observa como un deterioro principalmente en los aspectos psicológicos y somáticos. Este es el primer estudio que evalúa el impacto de la gravedad de la desnutrición, según los nuevos criterios GLIM 2019, sobre la calidad de vida de los pacientes con cáncer avanzado.

New technologies in breast cancer sentinel lymph node biopsy; from the current gold standard to artificial intelligence.

Sentinel lymph node biopsy is an important diagnostic procedure performed in early breast cancer patients with clinically negative axillary lymph nodes. Detection and examination of sentinel lymph nodes determine further therapy decisions, therefore a choice of optimal technique minimising the risk of false-negative results is of great importance. Currently, the gold standard is the dual technique comprising the blue dye and radiotracer, however, this method creates a logistical problem for many medical units. The intrinsic constraints of the existing methods led to the development of a very wide range of alternatives with varying clinical efficiency and feasibility. While each method presents with its own advantages and disadvantages, many techniques have improved enough to become a non-inferior alternative in the sentinel lymph node biopsy. Along with the improvement of the existing technologies, there are evolving trends such as multimodality of the techniques maximising the diagnostic outcome or an emerging use of artificial intelligence (AI) improving the workflow of the procedure. This literature review aims to give an overview of the current status of the standard techniques and emerging cutting-edge technologies in the sentinel lymph node biopsy.

Primary Ewing Sarcoma of the Thyroid-Eight Cases in a Decade: A Case Report and Literature Review.

Sarcomas represent less than 1% of all malignant tumors found in the thyroid. Of these, primary extraosseoussarcoma has been reported only a few times in the past decade. We present the case of a 34-year-old male who had a fast-growing hard mass in the lower left neck. FNA was inconclusive. Core needle biopsy revealed the diagnosis of an Ewing sarcoma/primitive neuroectodermal tumor. Mutation of EWSR1 was confirmed using the FISH method. Following treatment by neoadjuvant chemotherapy, we observed clinical, radiological, and finally histopathological remission. This was followed by a left-sided isthmolobectomy with unilateral cervical lymph node dissection by lateral lymphadenectomy, which revealed no residual disease. Posttreatment radiotherapy was administered but discontinued upon the patient's request. After 18 months of observation, the patient had no recurrence or metastasis and required l-thyroxine supplementation. We discuss our case using a comparative literature review to the few other known case reports.

Are bilateral breast cancers and breast cancers coexisting with ovarian cancer different from solitary tumors? A pair-matched immunohistochemical analysis aimed at intrinsic tumor phenotype.

Patients with bilateral breast cancer (BBC) and breast-ovarian cancer syndrome (BOCS) constitute populations potentially enriched for molecular defects involved in the pathomechanisms of these malignancies. The aim of our study was to compare tumor morphology and expression of estrogen and progesterone receptor, HER2, Ki67, cytokeratin 5/6, E-cadherin, vimentin and epidermal growth factor receptor in tissue microarrays from 199 tumors from BBC or BOCS patients and 199 age-matched solitary tumors. Compared to controls, BBC and BOCS considered jointly had lower incidence of DCIS, lower expression of PgR and HER2, and higher expression of Ki67 and vimentin. BOCS tumors were of higher grade, had lower expression of ER and PgR and higher expression of Ki67, CK5/6, vimentin and EGFR. BBC had less DCIS component, lower HER2 expression and higher Ki67 expression. Metachronous BBC (mBBC) had lower expression of ER, PgR and HER2, and higher expression of Ki67 and vimentin. Synchronous BBC (sBBC) had less DCIS component, higher expression of ER, and lower expression of CK5/6, EGFR and E-cadherin. BBC and breast cancers in BOCS differ in many aspects from solitary tumors. BBC are a heterogeneous group of tumors, differing between sBBC and mBBC. mBBC phenotype shares many features with BOCS tumors.

Prognostic relevance of demographics and surgical practice for patients with gastric cancer in two centers: in Poland versus Germany.

BACKGROUND: Although studies comparing the surgical treatment of gastric carcinoma in Japan and Western industrialized countries have revealed differing survival rates, no studies to date have been performed comparing Western and Eastern Europe. This study aimed to compare demographics and surgical practice as well as the related prognostic impact on gastric cancer patients treated in Poland and Germany. METHODS: This retrospective study included gastric cancer patients treated between 1999 and 2004 by surgical departments in Gdansk (Poland) and Cologne (Germany). Univariate and multivariate analyses of demographic, histopathological, surgical, and prognostic data were performed. RESULTS: Included were 117 patients from Gdansk and 130 patients from Cologne. The Cologne patients showed higher incidence rates of serious comorbidity, pT1 cancer, and distant metastasis than those from Gdansk. Indications for and frequency of selected surgical procedures differed significantly. D2-lymphadenectomy was performed in 89% of the Cologne patients, while D1-lymphadenectomy was done for 85% of the Gdansk patients. Univariate analysis yielded a 5-year survival rate of 28.3% for the Gdansk patients, and 40.3% for the Cologne patients (p = 0.056). Independent prognostic factors were pT category (p = 0.002), pN category (p < 0.001), pM category (p = 0.027), residual tumor (R) category (p = 0.004), age (p = 0.012), and number of resected lymph nodes (p = 0.005). CONCLUSIONS: Significant differences of clinical and surgical parameters exist between gastric cancer patients treated in Poland and Germany. In addition to established independent prognostic factors, we found that survival improved with each additionally resected lymph node.

Simultaneous surgery for critical aortic stenosis and gastric cancer: a case report.

We describe simultaneous surgery performed on a 71-year-old woman with critical aortic stenosis and gastric cancer that were diagnosed at the same time. The patient qualified for simultaneous surgery for both these diseases. Good early outcome was achieved. There is a lack of standards for treatment of patients with coexistence of two life-threatening conditions. We discuss surgical tactics and potential benefits of such management.

Possibilities of improving the parameters of hyperthermia in regional isolated limb perfusion using epidural bupivacaine and accurate temperature measurement of the three layers of limb tissue.

The present study presents the author's modification of the method, which aims to create proper parameters of the treatment. The selected group consisted of 15 women and eight men, with a mean age of 57.2 years (range from 26 to 72 years). The patients were divided into two groups, depending on whether they were given epidural bupivacaine (group I - 13 patients treated between the years 2001 and 2004) or not [group II (control) - 10 patients treated earlier, between the years 1997 and 2000]. We observed a significant change in the temperature of thigh muscles (P=0.009) and shank muscles (P=0.006). In the control group II, there was a statistically significant difference (P=0.048) in the temperatures between the muscles and subcutaneous tissue on the one hand and the shank skin on the other. That difference was mean 0.67 degrees Celsius (from 0.4 to 0.9) during the perfusion after applying the cytostatic. The temperature of the skin was lower than the temperature of the deeper tissues of the shank and did not exceed 39.9 degrees Celsius. Such a difference in the temperatures was not observed in case of the group I patients who were given bupivacaine into the extrameningeal space before applying the cytostatic. The difference in the temperatures was on average 0.26 degrees Celsius and was not statistically significant (P=0.99), whereas the shank skin temperature was 40.0-40.6 degrees Celsius. The attained results imply that despite the noticeable improvement in the heating of the limb muscles after application of bupivacaine, the improvement in the heating of the skin and subcutaneous tissue is still not satisfactory, although the growing tendency implies such a possibility.

Coexistence of hepatocellular carcinoma and gastrointestinal stromal tumor: a case report.

Malignant gastrointestinal stromal tumors (GIST) are rare mesenchymal tumors originating from the wall of the gastrointestinal tract. Their coexistence with other tumors originating from other germ layers is unique. We have reported a case of a 63-year-old GIST patient presenting as an epigastric mass associated with hepatic tumor. Histologically, the mesenteric tumor was composed of spindle cells showing both neural and smooth muscle differentiation. Immunohistochemical examination showed positive staining for CD117, vimentin, S-100, and SMA, while CD34 antigen was negative. The hepatic tumor was diagnosed as hepatocellular carcinoma (HCC). To the best of our knowledge, this is the first case of GIST and HCC coexistence. The rarity of the case, however, should not lead to ignoring such a possibility in differential diagnosis.