Selective sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer: results of the GEICAM 2005-07 study.

INTRODUCTION: A controversial aspect of breast cancer management is the use of sentinel lymph node biopsy (SLNB) in patients requiring neoadjuvant chemotherapy (NCT). This paper discusses the detection rate (DT) and false negatives (FN) of SLNB after NCT to investigate the influence of initial nodal disease and the protocols applied. METHODS: Prospective observational multicenter study in women with breast cancer, treated with NCT and SLNB post-NCT with subsequent lymphadenectomy. DT and FN rates were calculated, both overall and depending on the initial nodal status or the use of diagnostic protocols pre-SLNB. RESULTS: No differences in DT between initial node-negative cases and positive cases were found (89.8 vs. 84.4%, P=.437). Significant differences were found (94.1 vs. 56.5%, P=0,002) in the negative predictive value, which was lower when there was initial lymph node positivity, and a higher rate of FN, not significant (18.2 vs. 43.5%, P=.252) in the same cases. The axillary study before SLNB and after the NCT, significantly decreased the rate of FN in patients with initial involvement (55.6 vs 12.5, P=0,009). CONCLUSIONS: NCT means less DT and a higher rate of FN in subsequent SLNB, especially if there is initial nodal involvement. The use of protocols in axillary evaluation after administering the NCT and before BSGC, decreases the FN rate in these patients.

Chyle fistula in right cervical area after thyroid surgery.

Thoracic duct injury is an infrequent (1-2.5%) but severe complication after neck surgery, leading to nutritional, metabolic and immunologic deficiencies. We report a case of a 34-year-old woman with a right thoracic duct injury after surgery of a thyroid medullar cancer effectively treated with conservative management (parenteral nutrition and intravenous somatostatin). Optimal treatment of these patients is unclear, without a clear limit between conservative and surgical treatment.

Portal vein thrombosis after laparoscopic splenectomy in benign hematologic diseases.

INTRODUCTION: Portal vein thrombosis is an unfrequent, but potentially deadly, complication of the laparoscopic splenectomy procedure. The laparoscopic approach has shortened the duration of hospital stay; portal vein thrombosis may appear after the patient has left the hospital, determining a later diagnosis. Because of the mild, nonspecific symptoms, the diagnosis can even be missed and only achieved when chronic complications take place. OBJECTIVES: In this study, we aimed to determine the appearance of portal vein thrombosis in a consecutive series of patients who underwent laparoscopic splenectomy by performing a contrast-enhanced computed tomography (CT) scan postoperatively. MATERIALS AND METHODS: A transversal study was established, performing in 2005 a contrast-enhanced CT scan on 20 patients who underwent laparoscopic splenectomy between 1999 and 2005 at Ramón y Cajal University Hospital (Madrid, Spain). The presence of thrombosis in the splenoportomesenteric axis was investigated. RESULTS: Two (2) cases (10%) of portal vein thrombosis were detected: 1 symptomatic case, 7 days after surgery, was treated with anticoagulation, resulting in the disappearance of the thrombus in a new CT scan 6 months later; the second case was asymptomatic and was discovered during the performance of this study. CONCLUSIONS: The contrast-enhanced CT scan shows the best accuracy for the diagnosis of portal vein thrombosis, and it must be performed when any clinical manifestation appear; also, it must still be determined if a contrast-enhanced CT scan should be systematically performed in high-risk thromboembolic patients. An ultrasound Doppler may present many diagnostic errors. It is probably advisable to prolong the antithromboembolic prophylaxis.

[Laparoscopic splenectomy: 7-year experience]. / Esplenectomía laparoscópica: Experiencia de 7 años.

BACKGROUND: Laparoscopic splenectomy is an effective and safe technique in the management of benign splenic pathologies. METHODS: We reviewed our 7-year experience to evaluate utility and safety of this procedure. RESULTS: Laparoscopic splenectomy was performed in 20 patients (13 women, 7 men), with a mean age of 49 years. Pathology included 19 cases of idiopathic thrombocytopenic purpura (ITP) and one case of autoimmune hemolytic anemia. Mean operative time was 165 min, including anesthetic procedure. There was only one conversion to open surgery. Accessory spleens were detected in 15% of patients. Early remission of hematological disorders was achieved in 70% of the cases and long-term remission in 90%. The complications rate was 20%, including two cases of subphrenic hematoma, one case of acute focal pancreatitis and one case of thrombosis of the portal venous system; all recovered with no sequelae. Mortality rate was 0%. CONCLUSIONS: Laparoscopic splenectomy obtains results identical to those of open surgery in terms of efficacy and safety but with the benefits of laparoscopic surgery. Therefore, it should be considered as the procedure of choice for the treatment of benign hematological pathologies unresponsive to medical therapy.

Conservative treatment for infiltrating breast cancer. Ten years follow-up experience.

INTRODUCTION: We retrospectively analyze our experience in conservative treatment for infiltrating advanced breast cancer before implementation of selective sentinel node biopsy, specially focusing on characteristics, incidence, treatment and evolution of local-regional recurrences, disease-free survival time, overall survival and patient's satisfaction. MATERIAL AND METHODS: From January 1984 to 31st December 1998, 739 female patients were operated in our institution, diagnosed as having infiltrating breast cancer. One hundred and eighty-eight patients (25.43%) received conservative treatment and they were followed up until December 2003. RESULTS: Average age when diagnosed was 50.42 years old (24-87 years). 53.19% of the patients were premenopausal. After a median follow-up of 129 months (60-198 months), 13 women (6.91%) presented local -regional recurrence and the disease-free time was 48.4 months (8-108 months). Global survival rate was 83.5% and disease free survival rate was 80.85%. CONCLUSIONS: The management of choice for early stage (I and II) infiltrating breast cancer is nowadays conservative, with a low local-regional recurrence rate and survival rate that are comparable to radical mastectomy, according to the literature. It's a safe and efficient method that let us preserve the breast with a good esthetical result. In selected cases, when a regional recurrence occurs, a second conservative management is possible with a good control of the disease, although the most widely accepted treatment in these cases is total mastectomy.

Surgical considerations about amyloid goiter.

Amyloidosis is an uncommon syndrome consisting of a number of disorders having in common an extracellular deposit of fibrillary proteins. This results in functional and structural changes in the affected organs, depending on deposit location and severity. Amyloid infiltration of the thyroid gland may occur in 50% and up to 80% of patients with primary and secondary amyloidosis respectively. Amyloid goiter (AG) is a true rarity, usually found associated to secondary amyloidosis. AG may require surgical excision, usually because of compressive symptoms. We report the case of a patient with a big AG occurring in the course of a secondary amyloidosis associated to polyarticular onset juvenile idiopathic arthritis who underwent total thyroidectomy. Current literature is reviewed, an attempt is made to provide action guidelines, and some surgical considerations on this rare condition are given.

[Laparoscopic vs open splenectomy in the treatment of idiopathic thrombocytopenic purpura]. / Esplenectomía laparoscópica o esplenectomía abierta en el tratamiento de la púrpura trombocitopénica idiopática.

INTRODUCTION: Laparoscopic splenectomy (LS) is gaining acceptance as an effective and safe alternative to open splenectomy (OS) in the treatment of benign hematologic disorders unresponsive to medical treatment. Among these disorders, the most important is idiopathic thrombocytopenic purpura (ITP). PATIENTS AND METHOD: We compared a cohort of 20 patients who had undergone LS in the previous 7 years, with a historical cohort of 38 patients who underwent OS between 1985 and 1999. All patients in the two groups were diagnosed with ITP unresponsive to medical treatment. RESULTS: The mean age of the patients was 41 years in the LS group and 39.7 in the OS group. Mean spleen size and weight were 11 cm and 150 g in the LS group and 9.9 cm and 190 g in the OS group. Preoperative platelet count was 78 x 10(9) in the LS group and 69 x 10(9) in the OS group. Accessory spleens were detected in 15% of patients in the LS group and in 16% of those in the OS group. The mean operative time was 180 minutes in LS and 85 minutes in OS (p < 0.001). The complications rate was 25% in LS and 21% in OS. The mean length of hospital stay was 3 days in the LS group and 9.4 days in the OS group (p < 0.001). No differences were observed in early and complete long-term remission. CONCLUSIONS: Compared with OS, LS requires a longer operative time and reduces hospital stay. Detection of accessory spleens, complication rates, and effectiveness in terms of early and long-term remission are similar in both procedures. In our opinion, LS should be considered the procedure of choice for the treatment of benign hematological disorders unresponsive to medical therapy.

[Laparoscopic adrenalectomy]. / Adrenalectomía laparoscópica.

INTRODUCTION: In the last few years, laparoscopic adrenalectomy has become widely used in the management of adrenal disease. MATERIAL AND METHOD: We reviewed our experience of 24 patients who underwent laparoscopic adrenalectomy between 1998 and 2006. RESULTS: Surgery was indicated for Cushing's syndrome in 46% of the patients, aldosteronoma in 25%, incidentaloma in 21% and pheochromocytoma in 8%. A lateral transabdominal approach was employed in all patients. The mean age of the patients was 50.4 years (17 women and 7 men). Left unilateral adrenalectomy was performed in 63% of the patients, right unilateral adrenalectomy in 29% and bilateral adrenalectomy in 8%. The conversion rate was 4%. The mean operating time was 134 minutes in unilateral approaches and 245 minutes in bilateral approaches. The mean size of the gland was 4 cm. The complications rate was 4% and there was no mortality. Disease control was achieved in 96% of the patients after a mean follow-up of 49 months. CONCLUSIONS: Laparoscopic adrenalectomy should be considered the procedure of choice for the surgical management of benign adrenal disease.