Surgical Management of Locally Advanced Breast Cancer: Recommendations of the Brazilian Society of Surgical Oncology

The Brazilian Society of Oncological Surgery organized a group of oncological surgeons to discuss surgical aspects associated with locally advanced breast carcinoma. This article reviews the indications, the different surgeries (especially those associated with thoracoabdominal or myocutaneous flaps), and associated complications. It discusses special conditions such as invasion of the chest wall and interscapular thoracic disarticulation. It makes recommendations based on the literature regarding clinical findings, tumor conditions, response to neoadjuvant therapy, choice of flaps in surgery, and tumor biology.

Decreased Expression of Metastasis Suppressor 1 Correlates with Poor Prognosis of Patients with Rectal Adenocarcinoma

Background: Venous thromboembolic events (VTE) are common causes of morbidity and mortality in glioblastoma patients. Mutation in the isocitrate dehydrogenase 1 enzyme (IDH1) is frequent in secondary glioblastoma and results in altered metabolomics. Objectives: This study evaluates whether IDH-1 status correlates with incidence of VTE in glioblastoma patients. Methods: Observational study of 398 cases of patients with glioblastoma, who all underwent surgery in a regional Neurosurgical centre between April 2012 and December 2014. IDH -1 status and Tissue factor (F3) protein expression were assessed by immunohistochemistry. Deep venous thrombosis (DVT) and pulmonary embolism (PE) were diagnosed by Doppler ultrasound and pulmonary CT angiogram respectively. Results: 336 cases were wild type (WT) IDH-1 (94.1%) and 21 cases were IDH-1 mutated (R132H) (5.9%). 51 patients had a thromboembolic event (15.3%), with all cases of VTE in WT IDH-1 tumors, a rate of 21.8% within this group. IDH-1 status had a significant correlation with VTE (p=0.033 Fisher exact test). As expected, mutant IDH was associated with prolonged patient survival (p=0.024 Log rank). The mean expression in IDH-1 wild type GBM was 7.14 and in R132h mutant GBM was 4.87 (log2 scale). This was highly statistically significant with a corrected P value of less than 0.0001. Conclusion: A significant association exists between IDH1 status in glioblastoma patients and the risk of VTE. Patients with wild type IDH-1 appear at high risk of VTE and appropriate precautions should be considered.

Intraoperative Thrombolysis for Pulmonary Embolism during Thymoma Resection

We report a case of pulmonary embolism during resection of a mediastinal mass requiring intraoperative thrombolysis. The diagnosis, although difficult to establish due to simultaneous bleeding and technical difficulties with transthoracic echocardiography, was based on the patient’s history and clinical evidence of low cardiac output and was confirmed by clinical improvement post thrombolysis. When awakened in the intensive care unit, the patient was found to be blind and also required a tracheostomy. We present this case, as it requires complex clinical reasoning throughout different stages of its management and it demonstrates that, when facing an imminent disaster, a risky decision not necessarily conforming to current practice but based on individualisation of treatment can be life-saving.

Therapeutic Efficacy Evaluation and Underlying Mechanisms Prediction of Jianpi Liqi Decoction for Hepatocellular Carcinoma

Objective: The aim of this study was to assess the therapeutic effects of Jianpi Liqi decoction (JPLQD) in hepatocellular carcinoma (HCC) and explore its underlying mechanisms. Methods: The characteristics and outcomes of HCC patients with intermediate stage B who underwent sequential conventional transcatheter arterial chemoembolization (cTACE) and radiofrequency ablation (RFA) only or in conjunction with JPLQD were analysed retrospectively. The plasma proteins were screened using label-free quantitative proteomics analysis. The effective mechanisms of JPLQD were predicted through network pharmacology approach and partially verified by ELISA. Results: Clinical research demonstrated that the Karnofsky Performance Status (KPS), traditional Chinese medicine (TCM) syndrome scores, neutropenia and bilirubin, median progression-free survival (PFS), and median overall survival (OS) in HCC patients treated with JPLQD were superior to those in patients not treated with JPLQD (all P<0.05). The analysis of network pharmacology, combined with proteomics, suggested that 52 compounds targeted 80 potential targets, which were involved in the regulation of multiple signaling pathways, especially affecting the apoptosis-related pathways including TNF, p53, PI3K-AKT, and MAPK. Plasma IGFBP3 and CA2 were significantly up-regulated in HCC patients with sequential cTACE and RFA therapy treated with JPLQD than those in patients not treated with JPLQD (P<0.001). The AUC of the IGFBP3 and CA2 panel, estimated using ROC analysis for JPLQD efficacy evaluation, was 0.867. Conclusion: These data suggested that JPLQD improves the quality of life, prolongs the overall survival, protects liver function in HCC patients, and exhibits an anticancer activity against HCC. IGFBP3 and CA2 panels may be potential therapeutic targets and indicators in the efficacy evaluation for JPLQD treatment, and the effective mechanihsms involved in the regulation of multiple signaling pathways, possibly affected the regulation of apoptosis.

A Pilot Study for the Validation of Sentinel Lymph Node Biopsy with Indocyanine Green Fluorescence Method in Early Endometrial Cancer at Fundacion Jimenez Diaz University Hospital

Background: Sentinel Lymph Node Biopsy is a technique developed to predict lymphatic involvement in patients with early endometrial cancer, decreasing the morbimortality associated with routine systematic lymphadenectomy and improving quality of life. Main Objective: To determine the detection rate and negative predictive value of the Sentinel Lymph Node Biopsy by Immunofluorescence in patients with early endometrial cancer. Methods: A descriptive observational study in patients with early endometrial cancer (FIGO stage I-II) for all histological types and grades, who underwent the Sentinel Lymph Node by immunofluorescence Technique, between June 2019 and March 2020 at the Fundación Jiménez Díaz University Hospital. We used indocyanine green powder for injection, with a concentration of 25 milligrams (mg). We proceeded to dissolve it in 10 cubic centimeters (cc) of distilled water to. After which, we injected 2 cc of the prepared solution into the cervix at the 3 and 9 o’clock positions at a depth of 1 centimeter. Results: Eighteen patients were included, analysing a total of 26 sentinel nodes: 24 pelvic and 2 paraortic; and a total of 273 lymph nodes (sentinel and non-sentinel nodes): 83 right pelvic, 86 left pelvic and 104 paraortic. All nodes were negative for metastasis. Global and bilateral detection rates were 77.78% and 50% respectively. The Negative Predictive Value and sensitivity were 100%. No significant difference in morbimortality was found between performing only Sentinel Lymph Node technique or systematic lymphadenectomy, but the association with quality of life was significant, with better results for those who only underwent the sentinel lymph node technique versus systematic lymphadenectomy (0% vs 77%). Conclusion: The global and bilateral detection rates of the Sentinel Lymph Node Technique by immunofluorescence were 77.78% and 50% respectively, obtaining a Negative Predictive Value and Sensitivity of 100%. Sentinel Node Biopsy is a valid technique to predict lymphatic affectation in early endometrial cancer, with lower morbimortality than systematic lymphadenectomy.

Prognostic Significance of Survivin and Livin Expression in the Primary Breast Cancer and Their Lymph Node Metastases

Aim: To assess the prognostic significance of Survivin and Livin expression in invasive breast cancer and their lymph node metastases. Materials and Methods: The present series consists of archival samples from 78 women with invasive breast cancer diagnosed and treated during 2010-2014 at National Cancer Institute, Misurata, Libya. Tumor biopsies were analysed for expression of Survivin and Livin by immunohistochemistry, and different grading systems were tested for their expression. Results: In the cancer samples, a significant correlation was established between Survivin expression and site of the tumor (p=0.021), tumor recurrence (p=0.036), and unifocal tumor (p=0.001). Moreover, Her-2 negative tumors had higher Survivin expression than Her-2 positive tumors (p= 0.047). There were no associations between Survivin expression and histological grade, histological type, lymph node status, tumor stage, TNM classification, estrogen and progesterone receptors, distant metastases, chemotherapy, radiotherapy, hormone replacement, vascular invasion, surgical margin, positive family history. Livin expression in primary breast cancer showed a significant correlation (p=0.025) with positive family history, but no significant association with other clinicopathological parameters. In addition, we found that primary tumors showed higher Survivin expression (82%) compared with the lymph node metastases (34%), whereas Livin expression did not differ between the primary (71%) tumors and their metastases (84%). Conclusion: Survivin expression in primary breast cancer is significantly associated with several characteristics of favourable prognosis. Livin expression in primary breast cancer is significantly associated only with a positive family history of breast cancer.

Clinical Case of Castleman’s Disease Located at the Mesorectum

Introduction: A rare benign lymphoid proliferative disorder called Castleman’s disease is the most commonly presented as a solitary mass in the mediastinum, although sometimes with sites at the neck, axilla, mesentery, pancreas, pelvis and retroperitoneum. We report a case of Castleman’s disease in the mesorectum. According to the literature, such localization was visualized just in few cases all over the world. Case History: The patient was a 48-year-old man, who complained of lumbar pain. MRI was performed in 2014 on which the formation in the presacral mass of mesorectal fat (size up to 4,9*5,2*4,0 cm) on the level of S2 vertebrae was found, which is considered as a lymph node with the tendency to increase during 3, 5 years (+1cm). Upon admission to the clinic, differential diagnosis with lymphoma and malignant tumor were carried out. According to the colonoscopy, there were no evidence about any malignancies in the bowel. After laparoscopic removing of the mesorectal tumor and histological examination of the specimen immunohistochemistry assay was recommended. Following the analysis, the hyaline-vascular type of Castleman's disease was confirmed. Chemotherapy wasn’t recommended, because of radical surgical treatment. According to the results of monitoring in two years, no data of recurrence were identified. Conclusion: Castleman’s disease should be taken into consideration in the differential diagnosis of lymphoid formations in mesorectum.

Lymph Node Dissection for Colon Cancer in Older Patients: D2 or D3?

Background: The aim of the study is to compare the short-term and long-term results in the treatment of colon cancer in older patients with different extents of Lymph Node Dissection (LND). Materials and Methods: A retrospective multicenter study in general surgical geriatric department and specialized coloproctological hospitals of Sechenov University was performed between 2006 and 2015. Patients aged 75 years or older who underwent stage I-III colon cancer surgical treatment were included in the study. Groups were divided according to the extent of surgery: colon resection with D3 LND formed the study group and with D2 LND - the control group. Results: The mean age of patients in the study was 81±4 years. Charlson’s comorbidity index before surgery was higher in the D3 LND group (p <0.001). Surgical and anaesthetic risk had no significant differences between the groups (p=0.580). Operation time with D3 LND was 25 min longer than with D2 LND, with no differences in blood loss between the groups. Despite the increased surgery duration, prolonged ventilation time was similar (p=0.093). D3 LND results in increasing in postoperative morbidity (p=0.013) with no significant differences in 30-day, 90-day and 1-year mortality between the groups. D3 LND demonstrated significant improvement in five-year overall and disease-free survival. According to the multivariate analysis, male gender, stage III tumors and D2 LND increase the risk of death within five years after surgery. Conclusion: D3 LND in colon cancer surgical treatment in older patients does not affect the 30-day, 90-day, and one-year mortality and improves five-year overall and disease-free survival.

Improved Apical Margins with Use of Periurethral Suspension Stitch in Robotic Assisted Radical Prostatectomy

Introduction: Robotic surgery has transformed the standard treatment for localized prostate cancer. Oncologic control is at the foremost concern when treating prostate cancer. Previous studies have detailed the use of a periurethral suspension stitch during robotic assisted radical prostatectomy (RARP), but none have demonstrated significant improvement in surgical margins. Objective: The purpose of this study is to illustrate the use of a periurethral suspension stitch during RARP and its impact on apical surgical margin status. Methods: This study retrospectively analysed 97 patients who underwent RARP by a single high-volume robotic surgeon (TJM) between November 2011 and February 2014. The patients were split into two cohorts with one group (Suspended Stitch) having the dorsal venous complex (DVC) ligation stitch suspended while the second group having the DVC ligation stitch unsuspended (Unsuspended Stitch). Results: Positive margins were seen in 39.6% of patients in the Unsuspended Stitch group and 20.4% of patients in the Suspended Stitch group (p=0.04). Patients in the Unsuspended Stitch group had a Gleason score > 7 in 33.3% of cases, where patients in the Suspended Stitch group had a Gleason score > 7 in 57.1% of cases. Conclusion: Localized prostate cancer treatment has significantly changed with RARP. This study provides an additional technique for achieving improved oncologic control.

Hepatocellular Carcinoma in Cirrhotic Versus Non-Cirrhotic Patients: A Retrospective Study of 483 Patients

Background and Aim: Although cirrhosis is a classical risk factor for the development of hepatocellular carcinoma (HCC), its absence does not exclude this risk. We aimed to assess the clinical characteristics and outcomes of cirrhotic HCC (C-HCC) and non-cirrhotic HCC (NC-HCC) patients. Methods: Patients consecutively included in a prospective HCC cohort (University Hospital Bern) were analysed. They were categorised into two groups, based on the basis of histology or combined radiological and laboratory characteristics. Results: 20.4% of patients were NC-HCC. This group was characterized by a higher median age and a higher female prevalence compared to the C-HCC group. Non-alcoholic fatty liver disease (NAFLD) (25.7%) and HBV infection (14.9%) were the main risk factors in this group, whereas alcohol abuse (26%) and HCV (21.6%) in C-HCC, P<0.001. 19.4% of them were diagnosed during a screening programme. Resection was performed in 54.5% of NC HCC patients despite the advanced stage (BCLC stage B and C). No statistically significant difference in survival rate was observed between C and NC-HCC patients (24 months vs. 33.9 months, P=0.162). In multivariate analysis, in the NC-HCC group each unit increase in BMI was associated with mortality while liver transplantation and resection were positively associated with survival. In the C-HCC group, the BCLC stage C was negatively associated with survival while all the therapeutic lines were negative factors for mortality. Conclusion: NC-HCC patients were diagnosed more often outside a screening programme. The patients were older, with a higher female prevalence and despite an advanced stage, were often amenable to surgery.