Autofluorescence of parathyroid glands during endocrine surgery with minimally invasive technique.

PURPOSE: Accidental injury to the parathyroid glands (PTGs) is common during thyroid and parathyroid surgery. To overcome the limitation of naked eye in identifying the PTGs, intraoperative autofluorescence imaging has been embraced by an increasing number of surgeons. The aim of our study was to describe the technique and assess its utility in clinical practice. METHODS: Near-infrared (NIR) autofluorescence imaging was carried out during open parathyroid and thyroid surgery in 25 patients (NIR group), while other 26 patients underwent traditional PTG detection based on naked eye alone (NO-NIR group). Primary variables assessed for correlation between traditional approach and autofluorescence were number of PTGs identified and incidence of postoperative hypoparathyroidism (hypoPT). RESULTS: 81.9% of PTGs were detected by means of fluorescence imaging and 74.5% with visual inspection alone, with an average of 2.72 PTGs visualized per patient using NIR imaging versus approximately 2.4 per patient using naked eye (p = 0.38). Considering only the more complex total thyroidectomies (TTs), the difference was almost statistically significant (p = 0.06). Although not statistically significant, the observed postoperative hypoPT rate was lower in the NIR group. CONCLUSION: Despite the limitations and technical aspects still to be investigated, fluorescence seems to reduce this complication rate by improving the intraoperative detection of the PTGs.

ΔKi67 proliferation index as independent predictive and prognostic factor of outcome in luminal breast cancer: data from neoadjuvant letrozole-based treatment.

A key tool for monitoring breast cancer patients under neoadjuvant treatment is the identification of reliable predictive markers. Ki67 has been identified as a prognostic and predictive marker in ER-positive breast cancer. Ninety ER-positive, HER2 negative locally advanced breast cancer patients received letrozole (2.5 mg daily) and cyclophosphamide (50 mg daily) with/without Sorafenib (400 mg/bid daily) for 6 months before undergoing surgery. Ki67 expression and tumor size measured with caliber were determined at baseline, after 30 days of treatment and at the end of treatment. Patients were assigned to a clinical response category according to Response Evaluation Criteria in Solid Tumors, both at 30 days and before surgery and further classified as high-responder and low-responder according to the median variation of Ki67 values between biopsy and 30 days and between biopsy and surgery time. The predictive role of Ki67 and its changes with regard to clinical response and survival was analyzed. No differences in terms of survival outcomes emerged between the arms of treatment, while we observed a higher percentage of women with progression or stable disease in arm with the combination containing Sorafenib (20.5% vs 7.1%, p = 0.06). Clinical complete responders experienced a greater overall variation in Ki67 when compared with partial responders and patients with progressive/stable disease (66.7% vs 30.7%, p = 0.009). High responders showed a better outcome than low responders in terms of both disease-free survival (p = 0.009) and overall survival (p = 0.002). ΔKi67 score evaluated between basal and residual tumor at definitive surgery showed to be highly predictive of clinical complete response, and a potential parameter to be used for predicting disease-free survival and overall survival in luminal breast cancer treated with neoadjuvant endocrine-based therapy.

Management of the axilla in breast cancer: outcome analysis in a series of ductal versus lobular invasive cancers.

INTRODUCTION: Axillary lymph node dissection (ALND) has been considered essential for the staging of breast cancer (BC). As the impact of tumor biology on clinical outcomes is recognized, a surgical de-escalation approach is being implemented. We performed a retrospective study focused on surgical management of the axilla in invasive lobular carcinoma (ILC) versus invasive ductal carcinoma (IDC). MATERIALS AND METHODS: 1151 newly diagnosed BCs, IDCs (79.6%) or ILCs (20.4%), were selected among patients treated at our Breast Cancer Unit from 2012 to 2018. Tumor characteristics and clinical information were collected and predictors of further metastasis after positive sentinel lymph node biopsy (SLNB) analyzed in relation to disease-free survival (DFS) and overall survival (OS). RESULTS: 27.5% of patients with ILC had ≥ 3 metastatic lymph nodes at ALND after positive SLNB versus 11.48% of IDCs (p = 0.04). Risk predictors of further metastasis at ALND were the presence of > 2 positive lymph nodes at SLNB (OR = 4.72, 95% CI 1.15-19.5 p = 0.03), T3-T4 tumors (OR = 4.93, 95% CI 1.10-22.2, p = 0.03) and Non-Luminal BC (OR = 2.74, 95% CI 1.16-6.50, p = 0.02). The lobular histotype was not associated with the risk of further metastasis at ALND (OR = 1.62, 95% CI 0.77-3.41, p = 0.20). CONCLUSIONS: ILC histology is not associated with higher risk of further metastasis at ALND in our analysis. However, surgical management decisions should be taken considering tumor histotype, biology and expected sensitivity to adjuvant therapies.

Efficacy of extended aromatase inhibitors for hormone-receptor-positive breast cancer: A literature-based meta-analysis of randomized trials.

BACKGROUND: Endocrine treatment with Tamoxifen and aromatase inhibitors (AIs) is a staple in the management of hormone receptor positive breast cancer (HR + BC). It has become clear that HR + BC carries a consistent risk of relapse up to 15 years post-diagnosis. While increasing evidence supports the use of extended adjuvant Tamoxifen over 5 years, controversial data are available on the optimal duration of extended AIs adjuvant treatment. We performed a meta-analysis to assess the real impact of extended adjuvant therapy with AIs on disease-free survival (DFS). METHODS: A literature-based meta-analysis of randomized controlled trials (RCTs) was undertaken. Relevant publications from PubMed, the Cochrane Library, and abstracts from American Society of Clinical Oncology (ASCO) and San Antonio Breast Cancer (SABCS) symposia were searched. Primary and secondary endpoints were Disease Free Survival (DFS) and overall survival (OS) respectively. A subgroup analysis was also performed to elucidate the impact of nodal involvement. RESULTS: The pooled analysis revealed a significant increase in DFS in the extended AIs group (hazard ratio (HR): 0.78, 95% CI: 0.68-0.90; P = 0.0006). The subgroup analysis according to nodal status showed a greater DFS benefit with extended AIs in patients with positive nodes (HR = 0.67 versus 0.80). Our analysis also demonstrated no improvement in OS with extended AIs (HR = 0.99, 95%CI: 0.87-1.12; P = 0.84). CONCLUSION: This work confirmed the efficacy of extended adjuvant treatment with AIs for HR + early breast cancer, with a 22% increase in DFS, but no impact on OS. Greater efficacy was observed in women with positive nodal status.

Secondary breast angiosarcoma: A multicentre retrospective survey by the national Italian association of Breast Surgeons (ANISC).

BACKGROUND: Breast angiosarcoma is a malignant mesenchymal neoplasm, which accounts for approximately 2% of all soft tissue sarcomas. Secondary breast angiosarcoma (SBA) may be related to chronic lymphedema after a mastectomy with lymph node dissection (Stewart Treves syndrome) and previous radiotherapy for complications from breast radiation treatment. It is a very rare condition; therefore, diagnosis and management are still a challenge. METHODS: The ANISC collected SBA data by means of a survey sent to all Italian breast centres in the ANISC. The clinicopathological characteristics and the management of this disease were analysed. RESULTS: Twenty-four centres participated in this survey in which 112 cases of SBA were analysed. The median age of the women with SBA was 68.9 years and it appeared approximately 90 months after the first irradiation for breast cancer. In 92% of cases, a mastectomy was performed without axillary dissection for those patients having a high grade of SBA (74.2%). The prognosis was worse in the high-grade cases (overall survival-OS: 36 months) as compared with the low-grade cases (OS: 48 months). After a follow-up of 5 years, 50.5% of the patients were still alive. Disease-free survival (DFS) was 35 months, and there were no differences between the groups of patients with either high- or low-grade histology. CONCLUSIONS: Secondary breast angiosarcoma is a very aggressive disease associated with a short survival outcome. The surgical approach still remains an important step in the course of treatment; furthermore, an accurate histological examination is helpful in establishing the prognosis of the patient. A mastectomy is mandatory. A longer OS was observed in patients with low-grade angiosarcoma as compared to high-grade angiosarcoma (C.I. 40-57 vs. 31-41 months).

Advances in systemic therapy for metastatic breast cancer: future perspectives.

Breast cancer (BC) is the most common cancer in women worldwide. One in eight women will develop the disease in her lifetime. Notwithstanding the incredible progress made in this field, BC still represents the second most common cause of cancer-related death in women. Targeted drugs have revolutionised breast cancer treatment and improved the prognosis as well as the life expectancy of millions of women. However, the phenomenon of primary and secondary pharmacological resistance is becoming increasingly evident, limiting the efficacy of these agents and calling for a better in-depth knowledge and understanding of the biology as well as the biochemical crosstalk underlying the disease. The advent of laboratory technologies in the clinical setting such as the routine use of next generation sequencing has allowed identification of new genetic alterations as well as providing a precise picture of the molecular landscapes of each tumour. Consequently, new specific therapeutic approaches are becoming available to minimise or delay the occurrence of resistance. In this review, we analyse the latest research and news from the clinical development side for each BC subtype.

Abdominal asymmetry in a 17 year old girl.

The pseudopapillary pancreatic solid tumor (TPSP) is a rare malignancy typical of young adult women (only 12 pediatric cases from 2000 to 2009), it can recur and metastasize. The prognosis is usually good after radical surgical removal. We emphasize the importance of TPSP in differential diagnosis of retrogastric, peripancreatic masses especially in puberal females. We describe the case of an adolescent girl with an abdominal mass revealed as a rare pancreatic neoplasia.

Role of magnetic resonance imaging in managing selected women with newly diagnosed breast cancer.

The purpose of this study is evaluation of therapeutic impact of magnetic resonance imaging (MRI) in breast cancer patients that cannot be imaged adequately with traditional radiology: dense breasts, microcalcifications suspicious for carcinoma in situ or discordance between mammography and ultrasound. A review was performed of 493 patients' records: determination of breast MRI effect on clinical management was made for the selected 70 cases by analysing pre-MRI and post-MRI therapeutic plans. Analysis of final pathology was useful to determine if the change in surgical plan prompted by MRI was appropriate. Breast MRI added clinical information in 52.9% of patients that resulted in 44.3% of management changes that were judged as appropriate in 83.9% of cases. Breast MRI provides additional useful information, but causes more extensive surgery (40%) with no proven prognostic benefit. MRI should be considered optional in the clinical staging of breast cancer and performed in selected cases.

Laparoscopic mobilization of neovagina to assist secondary ileal vaginoplasty in male-to-female transsexuals.

OBJECTIVES: To describe 3 cases of successful laparoscopically assisted vaginal reconstruction using an ileal segment in patients with complete neovaginal stenosis. METHODS: We evaluated 5 male-to-female transsexual patients who required laparoscopic-assisted vaginal replacement for complete neovaginal stenosis after sex reassignment surgery. We performed complete laparoscopic vaginal isolation and mobilization, external configuration of the vagina, and laparoscopic-assisted vaginal anastomosis. RESULTS: No intraoperative complications occurred, and laparotomy conversion was not necessary. The mean length of the neovagina at the first postoperative visit was 13 cm. At a mean follow-up of 14 months, all patients were sexually active and completely satisfied with the operation. CONCLUSIONS: Our results have confirmed the feasibility of laparoscopic perineal neovagina construction by ileal colpoplasty. The cosmetic, functional, and anatomic results were encouraging. Isolated ileal segments provided excellent tissue for vaginal replacement, resulting in excellent patient satisfaction and relatively low morbidity. Furthermore, we report a modified surgical approach to conventional ileal vaginoplasty according to the Monti channel principle.

Transverse retubularized ileal vaginoplasty: a new application of the Monti principle--preliminary report.

OBJECTIVE: The surgical management of the absence of the vagina is a complex problem and constitutes a significant technical challenge. Herein we present our successful experience with vaginal reconstruction by the use of a modified ileal segment according to the Monti principle. METHODS: Six patients aged from 23 to 41 years (mean 33 years) were referred to our institution for vaginal stenosis. In our series, ileum has been used to create the neovagina: the isolated segment has been longitudinally detubularized and transversally retubularized in order to configure the roof of the neovagina. RESULTS: The mean operating time was 220 min. No intra-operative complication occurred. The mean follow-up of this series was 16 months. At the latest follow-up, all patients had patent moist neovaginas, but excessive vaginal mucous was not a problem in any patient in our series. CONCLUSIONS: Neovaginal creation using isolated ileal segments according to the Monti channel principle provide excellent tissue for vaginal replacement, providing excellent patient satisfaction and relatively low morbidity. Cosmetic, functional and anatomical results were encouraging. In our opinion our technique may be indicated for all cases of vaginal absence: congenital abnormalities in the pediatric population, vaginal stenosis after treatment of pelvic tumors, severe vaginal scarring secondary to chronic inflammatory disease or in case of secondary correction after failure gender surgery.

[Emergencies in colorectal carcinoma: negative prognostic factor?]. / L'urgenza da carcinoma colorettale fattore prognostico negativo?

The authors analyze a consecutive series of 219 patients affected by complicated colorectal cancer who underwent surgery in emergency. In hospital mortality, 5-year survival and recurrence's incidence in 104 of these patients who underwent curative treatment are calculated and compared with a series of 701 patients who underwent elective surgical treatment. There was no significative statistical difference between emergency and elective group. At the multivariate analysis only the stage of the tumor was an independent prognostic factor.

[The treatment of laparoscopic cholecystectomy for acute cholecystitis]. / Il trattamento della colecistite acuta in era laparoscopica.

The aim of the study is to evaluate the results of early laparoscopic cholecystectomy for acute cholecystitis and to analyse the problems related to patients' selection and surgical timing. The authors report their personal experience of 45 laparoscopic cholecystectomies for acute cholecystitis. The diagnosis was based on clinical, blood test and US scan analyse findings. Technical surgical details were decompression of the gallbladder, use of endobag and abdominal dranage. We didn't perform and intraoperative cholangiography in absence of predictive factor for common bile duct stones. The mean time required for surgery was 120 minutes, conversion rate was 15% in early operations and 23.8% in operations delaied more than 72 h. Dissection difficulty is the main cause of conversion. Four patients underwent postoperative complications: one subphrenic abscess, one bile leakage (both recovered with nonsurgical therapy and two wound infections). In conclusion laparoscopic cholecystectomy is safe and effective as early treatment of acute cholecystitis in the first 72 hours due to easier dissection of the inflammed and oedematous tissue. This approach allows a reduction of the operative risk and the conversion rate with medical and economic advantages. Presence of bile duct stones is still now indication to conversion in open surgery.

[Indications for splenectomy in the surgical treatment of gastric cancer]. / Indicazioni alla splenectomia nel trattamento chirurgico del cancro gastrico.

The extent of lymphadenectomy in the treatment of gastric cancer is still a matter of debate. Splenectomy, which has to be performed using the common surgical techniques to remove the lymph nodes of the splenic hilus, is part of this problem. The indications for splenectomy in the treatment of gastric cancer are examined, considering the results in terms of operative mortality and morbidity and long term survival. The Authors analyze a consecutive series of 129 patients who underwent total gastrectomy with D2 or D3 lymphadenectomy for gastric cancer. Forty-seven splenectomies were performed among 79 patients submitted to total gastrectomy. Splenectomy did not influence the perioperative mortality. Morbidity was higher in the patients who underwent splenectomy (33.3%) than in the patients without splenectomy (28.12%). This difference was not statistically significant. Five-year survival was higher in the group that did not undergo splenectomy (37.6% vs 27%) without any significant difference. Also considering the results in literature, splenectomy is associated with an increase in morbidity, and, for some authors, also in mortality, without any significant improvement in long-term survival. The indication for splenectomy in gastric cancer is based on an accurate evaluation of the localization and the depth of the parietal infiltration of the tumor.

[Pancreatic cystadenoma: report of 2 clinical cases and review of the literature]. / Cistoadenomi pancreatici: presentazione di due casi clinici e revisione della letteratura.

The Authors present two rare cases of pancreatic serous cystadenomas. Preoperative diagnosis of these neoplasms is very difficult despite the routine use of echotomography and CT, because the definitive diagnosis is provided only by histological examination of the surgical specimen. General agreement exists as to surgical indication. Surgical tactics depend on tumour localization: duodenocephalopancreatectomy for tumours of the head of the pancreas, and distal pancreatectomy for tumours located in the tail, as can be seen from a review of the recent literature. In both cases reported, the neoplasm was located in the pancreatic body. The treatment consisted in distal pancreatectomy. Splenectomy was necessary only in one of the two cases. During the follow-up the first patient died after 11 years without relapse. The second died 10 months postoperatively of an undifferentiated low rectal cancer. CT scans and sequential laparotomy showed no local relapse of the pancreatic tumours.

[Leiomyosarcoma of the inferior vena cava: a case report]. / Leiomiosarcoma della vena cava inferiore: a proposito di un caso.

Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare vascular tumour, with about 200 cases reported since 1871. The Authors report a case of leiomyosarcoma of the suprarenal inferior vena cava preoperatively diagnosed by ultrasonography and computed tomography. A surgical resection and venous wall reconstruction was performed. Complete surgical resection with a tumour-free margin (1 cm) is the treatment of choice. Neoadjuvant therapy may be given to downsize the tumour and increase resectability rate. When complete resection is not possible, debulking combined with radiation therapy provides good palliation.

Laparoscopic repair of a Morgagni-Larrey hernia.

The authors report a case of a large Morgagni hernia treated by laparoscopy. The patient complained of dyspnea, cough, and a sensation of tightness in the chest 1 month prior to admission. Preoperative diagnosis was made by chest x-ray, CT scan, and MRI, which showed a large right paracardiac mass consisting of an omentum and transverse colon. By reducing the hernial content, a 6 x 10-cm defect was revealed; the repair was performed with a Marlex mesh sutured by a hernia stapler. Postoperative recovery was uneventful, and 3 months after surgery the patient is well. Laparoscopic treatment of a Morgagni hernia provides an excellent view of the surgical field and ease of execution, joined with a minimal surgical trauma with rapid recovery for the patient.

[Management of breast cancer in geriatric age; observations on 164 cases]. / La terapia del cancro della mammella in età geriatrica: considerazioni su 164 casi osservati.

Progressive increasing of the life expectancy and the ever more frequent finding of breast cancer in elderly women have focused the attention on the treatment of this pathology in the elderly women. Today most studies support a more aggressive locoregional and systemic therapy in older patients in good physical condition. Authors analyze retrospectively a series of 164 women with breast cancer aged over 69 years treated with combined modality therapy regarding the stage of disease and the status of the patient. Survival by stage, tumor characteristics, node involvement have been compared with a series of patients less than 70 years treated on the same period. Survival curves were not significantly different between the two groups, except for T1 which showed a better survival in younger patients. Also survival according to node involvement did not show significant differences between the two groups. in conclusion, older women should be treated with the same surgical procedures, according to stage, of the younger patients, if they are not too frail to undergo surgery. Only the definitive results of prospective randomized trials will better define the indications and limits of a further reduction of the extent of surgical excision.

Laparoscopic surgery for diverticulitis.

BACKGROUND: Resection of diverticular disease may be quite challenging; the acute inflammatory process, thick sigmoid mesentery, and any associated fistula or abscess can make this procedure technically demanding. The aim of this study was to compare the results between laparoscopic and laparotomy-type resections stratified by disease severity and thereby predict outcome and possibly a subset of patients who may benefit from a laparoscopic approach. METHODS: From August 1991 to December 1995, all patients with diverticular disease were classified according to a modified Hinchey classification system. The laparoscopic group included 18 patients who underwent a laparoscopic assisted colectomy, one with a loop ileostomy. The identical procedures were performed in 18 patients by laparotomy. The mean age of the two groups were 62.8 and 67.1 years, respectively (p = NS). RESULTS: Seven of 18 patients in whom laparoscopy was attempted (38.9%) had conversion to laparotomy. Six of seven (85.7%) conversions were directly related to the intense inflammatory process. Laparoscopic treated patients with Hinchey IIa or IIb disease had a morbidity rate of 33.3% and a conversion rate of 50% while all patients with Hinchey I disease were successfully completed without morbidity or conversions to laparotomy. However, after the first four cases, the intraoperative morbidity and postoperative morbidity rates were zero and 14.3% and after ten cases they were zero and zero, respectively. Furthermore, the median length of hospitalization for Hinchey I patients after laparoscopy was 5.0 days vs 7 days after laparotomy (p < 0.05). In Hinchey IIa and IIb patients, the median length of hospitalization was almost 50% shorter with a laparoscopic approach (6 days vs 10 days, p < 0.05). CONCLUSION: In conclusion, laparoscopic resection of diverticulitis can be performed without additional morbidity particularly in Hinchey I patients and with a reduced length of hospitalization in patients with class I or II disease. Patients with class I disease, and after initial experience even those with class II disease, can benefit from the reduced morbidity and length of hospitalization associated with laparoscopic treatment.