Additional Cavity Shaving at the Time of Breast-Conserving Surgery Enhances Accuracy of Margin Status Examination.

PURPOSE: We addressed the impact of separate cavity margin excision (shaving) during breast-conserving surgery (BCS) for breast cancer on specimen volume, tumor margin clearance, re-excision rate, local recurrence and survival. METHODS: A retrospective case-matched study was performed on 298 women with stage 0-III breast cancer; 179 patients received shaving (shaving + lumpectomy group; SLG) and 119 patients did not (lumpectomy group; LG). RESULTS: The two groups had similar baseline characteristics. The median volume of surgical specimen was 131.9 cc in the SLG versus 134.8 cc in the LG (p = 0.81), and surgical margins were tumor-free in 90.7 % of cases in the LG versus 92.7 % in the SLG (87.1 % before shaving) (p = 0.69). The re-excision rate was 14.3 % in the LG versus 10.6 % in the SLG (p = 0.44). In the SLG, shaving spared 10 (5.6 %) patients from reoperation (positive lumpectomy margins but tumor-free shaving margins) (p = 0.11), and only 2/19 (10.5 %) patients in the SLG had tumor-free response at histological examination of re-excised margins compared with 10/17 (58.8 %) cases in the LG (p = 0.004). Tumor in shavings was found in 44/156 (28.2 %) patients having tumor-free lumpectomy margins. At multivariate analysis, distance of tumor from lumpectomy margins, tumor multifocality, receptor status, and tumor size were related to tumor persistence in shavings. Median follow-up was 27 months (range 23-35), and two patients had tumor relapse in the SLG versus none in the LG (p = 0.16). Overall survival was 100 % in both groups. CONCLUSIONS: Shaving does not significantly decrease the re-excision rate but provides wider clear margins in most procedures. It ensures more accurate margin examination and decreases false-positive margin rate, without any increase in removed breast-tissue volume.

Perivascular epithelioid cell tumor located retroperitoneally with pulmonary lymphangioleiomyomatosis: report of a case.

Perivascular epithelioid cell neoplasms, also known as "PEComas", are unusual mesenchymal tumors, exhibiting perivascular epithelioid cell differentiation and characterized by a mixed myogenic and melanocytic phenotype. "PEComas not otherwise specified" (PEComas-NOS) are especially rare; consequently, there are no published large series, but only case reports. These tumors are rarely located retroperitoneally, with only about 15 such cases reported. We report a case of pulmonary diffuse lymphangioleiomyomatosis with large retroperitoneal PEComa-NOS in a 66-year-old woman. Treatment consisted only of tumor resection, without additional adjuvant therapy. We emphasize the importance of correct immunohistochemistry diagnosis, initiation of recommended treatment, and surveillance of this unique family of tumors.

Impact of obesity on early surgical and oncologic outcomes after total gastrectomy with "over-D1" lymphadenectomy for gastric cancer.

INTRODUCTION: The purpose of the present study was to assess the impact of body mass index (BMI) on perioperative and pathologic outcomes after total gastrectomy with "over-D1" dissection for gastric cancer. METHODS: Data on 161 patients undergoing total gastrectomy between 2005 and 2011 were reviewed. Patients were grouped into three categories by BMI: BMI < 25 kg/m(2) (63 normal-weight patients; 39.1 %), BMI ≥ 25-<30 kg/m(2) (73 overweight patients; 45.3 %), and BMI ≥ 30 kg/m(2) (25 obese patients; 15.6 %) and matched for the analysis of perioperative and cancer-related outcomes. RESULTS: Operative time was longer for obese patients. Medical (mainly pulmonary) and surgical (mainly bleeding and wound infection) complications occurred more frequently in overweight/obese subjects. However, they were mostly managed conservatively (grade I-II in the Clavien-Dindo classification). The overall postoperative mortality was 0.9 %. Multivariate analysis identified the American Society of Anesthesiologists score and splenectomy, but not obesity, as independent risk factors for postoperative complications. The median number of lymph nodes retrieved differed significantly from group to group: obese 21 (IQR 18-26), versus overweight 24, versus normal weight 28 (p = 0.031). No difference was found in lymph node ratio and cancer-related parameters. CONCLUSIONS: Obese patients with operable gastric cancer can be candidates for standard extensive surgical resection, provided that pre-existing co-morbidities and potential intraoperative and postoperative complications are considered.

Outcomes of open splenectomy for hematologic malignancy with splenomegaly: a contemporary perspective.

Splenectomy for hematologic malignancy (HM) is considered a high-risk procedure, especially in cases of splenomegaly. We analyzed the postoperative course of 82 patients undergoing open splenectomy for HM-related splenomegaly (splenic craniocaudal length 15 cm or greater) in a high-volume center. Primary outcome measures were: perioperative clinical course, rate and severity of postoperative complications (Clavien-Dindo classification), and length of hospital stay. Risk factors analyzed for morbidity and mortality by logistic regression analysis were: gender, age, American Society of Anesthesiologists (ASA)grade, body mass index (BMI), steroidal treatment, preoperative white blood cell count, spleen size, spleen weight, and operative time. The postoperative mortality rate was 1.2 per cent. Only 15.9 per cent of patients required surgical, endoscopic, or radiological intervention after splenectomy (Grade 3 or greater complication). Overall postoperative morbidity rate (as Grade 2 or greater complication) was 52.4 per cent. Surgical complications, mainly bleeding, occurred in 40.2 per cent of patients and 32.9 per cent of patients required blood transfusion. Medical complication rate was 24.4 per cent. Pulmonary disorders were prevalent among medical complications. At multivariate analysis, only ASA score was an independent risk factor for postoperative complications. Open splenectomy can be performed in high-volume centers with low mortality and acceptable morbidity in patients with HM-related splenomegaly, provided that patients at highest risk of postoperative complication (ASA greater than 3) are carefully evaluated.

Iatrogenic rectovaginal fistula repair by trans-perineal approach and pubo-coccygeus muscle interposition.

INTRODUCTION: Rectovaginal fistula (RVF) is a rare but debilitating complication of a variety of pelvic surgical procedures. PRESENTATION OF CASE: We report the case of a 45-year-old female who underwent the STARR (Stapled Trans Anal Rectal Resection) procedure, that was complicated by a 30mm rectovaginal fistula (RVF). We successfully repaired the fistula by trans-perineal approach and pubo-coccygeus muscle interposition. Seven months later we can confirm the complete fistula healing and good patient's quality of life. We carefully describe our technique showing the advantages over alternative suturing, flap reconstruction or resection procedures. DISCUSSION: This technique is fairly easy to perform and conservative. The pubo-coccygeus muscle is quickly recognizable during the dissection of the recto-vaginal space and the tension-free approximation of this muscle by single sutures represents an easy way of replacement of the recto-vaginal septum. CONCLUSION: In our experience the use of pubo-coccygeus muscle interposition is an effective technique for rectovaginal space reconstruction and it should be considered as a viable solution for RVF repair.

A mammary nodule mimicking breast cancer.

Metastases to the breast from extramammary tumors are rare. Several clinical, radiologic, and histologic signs can help to distinguish metastases from breast primary tumors. In the present study, we present a case of a left-sided breast metastasis from renal cancer in a 44-year-old woman whose clinical presentation was a mammary nodule in the upper internal quadrant. The patient underwent quadrantectomy with sentinel lymph node biopsy. The histology revealed a clear cell carcinoma. On computed tomography scan a 5×8-cm left renal mass with pulmonary, liver, and intrapericardial nodules was found. The patient underwent palliative care and died after 4 months. Metastasis to the breast is rare, but all of those clinical, radiologic, and histologic signs more typical of extramammary malignancies should always be considered in order to choose the best treatment strategy.

INvolvement of breast CAncer patients during oncological consultations: a multicentre randomised controlled trial--the INCA study protocol.

INTRODUCTION: Studies on patient involvement show that physicians make few attempts to involve their patients who ask few questions if not facilitated. On the other hand, the patients who participate in the decision-making process show greater treatment adherence and have better health outcomes. Different methods to encourage the active participation during oncological consultation have been described; however, similar studies in Italy are lacking. The aims of the present study are to (1) assess the effects of a preconsultation intervention to increase the involvement of breast cancer patients during the consultation, and (2) explore the role of the attending companions in the information exchange during consultation. METHODS AND ANALYSIS: All female patients with breast cancer who attend the Oncology Out-patient Services for the first time will provide an informed consent to participate in the study. They are randomly assigned to the intervention or to the control group. The intervention consists of the presentation of a list of relevant illness-related questions, called a question prompt sheet. The primary outcome measure of the efficacy of the intervention is the number of questions asked by patients during the consultation. Secondary outcomes are the involvement of the patient by the oncologist; the patient's perceived achievement of her information needs; the patient's satisfaction and ability to cope; the quality of the doctor-patient relationship in terms of patient-centeredness; and the number of questions asked by the patient's companions and their involvement during the consultation. All outcome measures are supposed to significantly increase in the intervention group. ETHICS AND DISSEMINATION: The study was approved by the local Ethics Committee of the Hospital Trust of Verona. Study findings will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01510964.

Total gastrectomy with "over-D1" lymph node dissection: what is the actual impact of age?

BACKGROUND: We aimed to evaluate risk factors for postoperative complications after total gastrectomy with "over-D1" lymphadenectomy. METHODS: Data on 161 patients (54 cases aged >75 years: elderly group) operated on between 2005 and 2011 were reviewed. Risk factors analyzed for complications (Clavien-Dindo classification) included sex, age, American Society of Anesthesiologists (ASA) grade, body mass index (BMI), pTNM stage, long-term antiplatelets therapy, operative time, and splenectomy. RESULTS: The median age of the study population was 71 (interquartile range [IQR] 62-77) years (79 [range 76-90] years for elderly patients vs 65 [range 33-75] years for the control group, P < .0001). ASA classification was the only baseline characteristic significantly different in the intergroup analysis; 79.6% of the elderly patients were in ASA class III to IV versus 39.2% of the controls (P < .0001). Univariate analysis showed that patient age, ASA score, BMI, and splenectomy were predictive of postoperative complications. Multivariate analysis confirmed ASA score and splenectomy as independent risk-factors. CONCLUSIONS: Regardless of age, fit elderly patients with operable gastric cancer should be candidates for the recommended standard extensive surgical resection provided that pre-existing comorbidities are considered.