Extent of surgical procedure in triple negative breast carcinomas.

INTRODUCTION: Triple negative breast carcinomas (TNBC) account for approximately 15-20% of all breast carcinomas. This subtype is characterised by an unfavourable prognosis with early locoregional recurrence a metastases. Only few studies have focused on the impact of local surgery on the overall therapeutic outcome. However, decisions are difficult to make in the case of TNBC, and no particular molecular subtype or marker exists that would make the decision-making process easier. The aim of our retrospective study was to analyse the TNBC surgical management outcomes at EUC Clinic in Zlin. METHODS: 440 women with breast carcinoma were operated on at EUC Clinic from 2014 to 2016, including 29 patients with TNBC; bilateral carcinoma was present in one case. Neoadjuvant chemotherapy (NAC) was indicated in 6 cases. The tumour centre was marked with a clip. The extent of surgery depended on the residual size of the tumour. Sentinel lymph node biopsy was indicated in clinically negative lymph nodes; further management followed the Z0011 study if the biopsy was positive. Axillary lymph node dissection was performed after NAC. In all cases, surgery was followed by systemic chemotherapy, and by radiotherapy in the case of breast-conserving procedures. RESULTS: The group included 29 women and one patient with bilateral carcinoma, i.e. 30 cases of TNBC. Mean age was 57 years and median age was 55.5 years. Mean follow-up was 62.9 months, with the median of 69.9 month. NAC was indicated in 6 patients; complete pathological response was achieved in one case. NAC was followed by mastectomy in 5 cases including a bilateral procedure in one case, and by breast-conserving surgery in one case. Axillary dissection was performed in all cases. Breast-conserving surgery and sentinel node biopsy predominated in the group (16 cases). Local recurrence was observed in 4 cases, 2 times as an isolated local recurrence after one year and 2 times as part of generalization, always after mastectomy. Six patients died of generalized disease. No regional recurrence was observed. CONCLUSION: TNBC is characterised by a worse prognosis and a higher rate of local recurrence. As confirmed by our study, the results of breast-conserving surgery can be comparable to those of radical procedures, and thus radical surgery should be indicated prudently.

The importance of sentinel lymph node biopsy following neoadjuvant chemotherapy in patients with breast cancer: prospective multicentre trial.

INTRODUCTION: The role of sentinel lymph node biopsy (SLNB) in patients with breast cancer after neoadjuvant chemotherapy (NAC) is currently under discussion. The aim of our study was to determine the false negativity rate (FNR) of SLNB, the accuracy of ultrasound examination in the evaluation of the status of lymph nodes and the accuracy of perioperative cryobiopsy of the sentinel lymph node (SLN). METHODS: Prospective multicentre study, which took place in years 20182020 at three centres in the Czech Republic. A total of 59 patients were evaluated. RESULTS: The FNR of SLNB in the group of patients with cN1 before NAC and ycN0 after NAC was 12.5%. The FNR of perioperative histological examination of the SLN was 38.5%. The FNR of ultrasound examination of axillary lymph nodes in patients after NAC was 35.5%, and the false positivity rate was 16.7%. The incidence of inflammatory complications in our cohort was 3.3%. CONCLUSION: The FNR of SLNB in the group of patients with cN1 before NAC and ycN0 after NAC exceeds the tolerable limit of 10%. The FNR of perioperative histological examination of the SLN is high; definitive histological examination of the SLN may change the original diagnostic-therapeutic plan. Ultrasound examination of the axillary lymph nodes in patients after NAC is a method with high false negativity and positivity and may not correspond with the perioperative finding. The incidence of inflammatory complications in our cohort in patients after NAC is comparable to literature data on the frequency of complications in patients without NAC.

Ductal carcinoma in situ and the extent of surgery.

INTRODUCTION: Ductal carcinoma in situ (DCIS) is a very heterogenous disease. The incidence of DCIS has been increasing with the adoption of mammography screening. This opened new questions concerning surgical and adjuvant therapy.  Methods: We retrospectively observed the incidence of DCIS amongst the patients that underwent surgical resection in EUC clinic Zlín between 2017 and 2019. We also assessed the extent of breast surgery including interventions in axilla and the adjuvant therapy.  Results: There were 616 breast cancer patients, of whom 44 (7.1%) were diagnosed with DCIS. Breast-conserving surgery was performed in 35 (80%) patients. Lumpectomy alone was performed in 21 (47%) patients. Mastectomy was indicated primarily in 9 cases with additional two mastectomies performed to achieve clear margins. All sentinel nodes were negative.  Conclusion: Results confirmed, that the surgical therapy as well as radiotherapy and hormonal treatment are performed according to guidelines at our department. Proportion of sentinel node biopsy is remarkably higher, therefore an improvement in this area is our next goal.

Targeted axillary dissection with preoperative tattooing of biopsied positive axillary lymph nodes in breast cancer.

Sentinel lymph node biopsy (SLNB) has emerged as an alternative to axillary lymph node dissection during breast cancer surgery during the last 2 decades. However, there are several controversies regarding the indication of the sentinel node biopsy after neoadjuvant chemotherapy which can convert positive lymph nodes to negative. The false-negative rate after neoadjuvant chemotherapy is unacceptably high. This high false-negative rate can be decreased by marking of the positive lymph nodes and removal during sentinel lymph node biopsy procedure in addition to the sentinel lymph nodes. The aim of this study was to investigate the possibility of carbon tattooing of the positive sentinel lymph nodes before neoadjuvant chemotherapy. In 2016, a prospective protocol was launched investigating the black carbon tattooing procedure of the suspective and positive axillary lymph nodes by injecting 0.1-0.5 carbon ink in normal saline under ultrasound guidance. All patients underwent black carbon tattooing of the suspected or positive axillary lymph nodes before the chemotherapy or one week before the primary surgery when chemotherapy was not indicated in the neoadjuvant setting. Sentinel lymph nodes together with lymph nodes marked by the black carbon ink were removed and histologically evaluated. So far 27 patients were treated under this protocol. Breast saving surgery was performed in 22 cases and mastectomy in 5 cases. All patients had invasive ductal carcinoma. In 20 patients neoadjuvant chemotherapy was indicated and in 7 patients primary surgery was performed. All lymph nodes marked by black carbon ink were successfully identified and removed. Sentinel lymph node biopsy was performed in 8 cases and sentinel lymph node biopsy followed by axillary dissection in 15 cases. Axillary dissection alone was performed in 4 cases. In 19 cases, the black carbon ink was present in the sentinel lymph node at the same time and in 4 cases carbon dye was present in other lymph nodes than the lymph node identified during SLNB, which corresponds to 17.4%. In the group of patients undergoing primary surgery, in one case from six, the sentinel lymph node was negative and the lymph node marked with carbon ink positive which represents false-negative lymph node and failure of the SLNB procedure. After neoadjuvant chemotherapy, there was no false-negative lymph node identified, but the conversion of the positive lymph nodes to negative was present in 10 cases (50%). There were no complications attributed to carbon ink tattooing. The results of positive sentinel lymph nodes tattooing have confirmed that this method is safe and allows a decrease in the false negativity rate during the sentinel node biopsy procedure.

Surgical treatment of breast carcinoma after neoadjuvant therapy.

INTRODUCTION: Neoadjuvant therapy (NT) applied before breast cancer surgery can lead in favourable cases to regression of the tumor or its total disappearance - pathological complete response (pCR). Due to downstaging after NT, the extent of the surgery can be reduced. pCR represents an important prognostic factor for survival. The aim of this study was to evaluate the effectiveness of NT resulting in pCR on our sample of patients and to assess the frequency of locoregional recurrence (LRR) depending on the extent of the surgery in postoperative care. METHODS: This retrospective study was performed on a sample of 96 patients who underwent breast cancer surgery between 2006 and 2018 after previous NT. On the basis of the histological examination after surgery we evaluated the degree of regression and thus also pCR. In postoperative care we followed the patients for any occurrence of LRR in the breast and axilla. RESULTS: pCR (Chevallier 1) was observed in 26 cases - 27.1%. During follow-up in postoperative care, 8 cases of LRR occurred - 8.3% (5.2% after mastectomy and 2.1% after breast-conserving surgery). Mean follow-up was almost 30 months with the median of 26.5 months. CONCLUSION: With the development of new NT procedures a significant rise in pCR has occurred, predominantly in HER 2+ and triple negative subtypes, thus leading to a decreased incidence of LRR. The number of breast-conserving surgeries with sentinel lymph node biopsy is rising. In a select group of patients breast-conserving surgery is safe and is associated with a low number of LRR events.

Oncosurgery in the Czech Republic.

The article describes the development of oncosurgery in the Czech Republic since the beginning of the century, as well as other perspectives regarding this specialty. The development of surgical treatment of solid malignant tumours in the Czech Republic was evaluated according to the National Cancer Register database and compared to the neighbouring countries, and the educational system of surgeons in oncosurgery was assessed. Although surgery plays a key role in cancer therapy, starting from the beginning of this millennium it has been pushed aside as a service specialty for other disciplines in oncology. In 2002, these changes were supported by the activities of the newly founded Division of Oncosurgery under the Czech Society for Oncology, which became part of the Czech Surgical Society in 2016. An official educational programme of surgeons in oncology was successfully implemented and since 2011, a specialization examination in oncosurgery has been introduced, organized by the subdepartment of oncosurgery of the Institute of Postgraduate Medical Education (IPVZ), Prague. To date, this examination has been completed by 112 physicians and approximately the same number is currently registered in the educational programme. Currently, 34 centres are accredited for education in oncosurgery. The establishment of Complex Oncology Centres based on an initiative of the Czech Society for Oncology of 2006 only addressed pharmaceutical and radiation oncology. Despite progress in oncosurgery, more clearly defined conditions for this specialty are needed. Conclusion: The education of surgeons in oncosurgery should be continued. It is necessary to expand the number of centres with accreditation for oncosurgery and develop a concept for oncosurgery in the Czech Republic which would be associated with rational concentration of this treatment in connection with organization and provision of continuous urgent and acute surgical care in the Czech Republic, including control mechanisms to ensure its quality. This proposal should be discussed by the Czech Surgical Society in order to further enhance the quality of oncosurgery in the Czech Republic.

Bipolar radiofrequency-induced thermotherapy of haemorrhoids: a 10-year experience.

INTRODUCTION: Bipolar radiofrequency-induced thermotherapy of advanced stage haemorrhoid disease has been used successfully at the Atlas Hospital in Zlin for ten years. The aim of this study was to evaluate long-term outcomes of the method. METHOD: RFITTH is bipolar radiofrequency-induced thermotherapy of haemorrhoidal diseases. High frequency electric current causes thermal coagulation of tissue. The procedure results in the elimination or significant reduction of prolapse and bleeding of hemorrhoids. RESULTS: 228 RFITTH procedures were performed in 217 patients at the Department of Surgery at the Atlas Hospital from 9/2007 to 1/2017. The group consisted of 134 men and 94 women, the average age was 51 years. 107 operations were performed in stage III and 121 in stage IV. Complications of the procedure involved postoperative fissure occurring in 20 patients (8.7 %). Thrombotic haemorrhoid developed in 6 patients (2.6 %), hyperspasm of the sphincters in 9 patients (3.9 %). Prolapse of the rectal mucosa was diagnosed in 4 patients (1.7 %). The disease recurred in 9 patients and 10 reoperations were performed (3.9 %). CONCLUSION: The method is a safe miniinvasive therapeutic option for advanced stage haemorrhoidal disease. Key words: RFITTH - haemorrhoidal disease - radiofrequency coagulation.

[Is it possible to avoid axillary dissection?] / Muzeme se vyhnout disekci axilárních lymfatických uzlin?

The essential aim of oncology surgery including breast cancer is to remove the malignant tumour and lymph nodes. For many decades, dissection of axillary lymph nodes has been a common part of mastectomy, virtually the only surgical procedure in breast cancer treatment until the 90ies of the previous century. Although mastectomy has been replaced with breast preserving procedures, axillary dissection remained an integral part of the surgery. Sentinel lymph node biopsy (SLNB) has introduced a revolutionary change in breast cancer treatment in the axilla, replacing dissection in clinically negative axillary nodes. As a result, the number of radical procedures in the axilla was significantly limited, as well as the incidence of serious complications that may have a negative impact on the quality of life of the patients. As shown by other studies, the number of dissections can be reduced even further. Subsequent axillary dissection is unnecessary where the sentinel nodes contain only malignant cells, micrometastases and even a limited number of macrometastases. SLNB can also be used in a selected group of patients after neoadjuvant chemotherapy.Key words: breast carcinoma - axillary dissection - sentinel lymph node - micrometastases - macrometastases.

[Internal mammary lymph nodes in early stage breast cancer]. / Vnitrní mamární uzliny u casného karcinomu prsu.

Internal mammary nodes (IMN) in early stage breast cancer are a still unresolved issue. Their involvement has a crucial impact on the staging as well as prognosis of the breast cancer patients. The reported incidence of IMN drainage in the process of detecting the axillary sentinel node is about 20% depending on the tracer application technique. However, the IMN drainage itself apparently has no effect on the prognosis even when the nodes are left without biopsy or radiotherapy. The major predictive factor for the presence of metastases in IMN is the presence of metastases in axillary lymph nodes. Studies evaluating adjuvant IMN radiotherapy have shown inconsistent outcomes. The generally accepted trend towards less extensive locoregional procedures in breast cancer treatment will apparently affect the IMN, as well, given that new systemic treatment will probably compensate for uncertainties in IMN management.Key words: breast cancer internal mammary nodes radiotherapy.

[Microscopic tumor cells in re-excision tissue by conservative surgery in breast cancer]. / Mikroskopické nádorové reziduum v reexcidované tkáni po konzervativních výkonech na prsu pro karcinom.

INTRODUCTION: Conservative procedures in early breast carcinoma are a safe alternative to mastectomy. The resection line is controversial, as well as the presence of residual malignant cells in the breast after excision and their influence on local recurrence. The aim of the study was to assess the presence of residual cells in re-excised tissues near positive resection lines, in the distance up to 2 mm, and 2-5 mm. The distance of more than 5 mm was evaluated as free margin. METHOD: All patients operated on in Atlas Hospital from 2004 to 2008 using conservative surgery were included in study. The resection line and the presence of residual malignant cells were followed in positive margins and in the distance of the resection line from the tumour up to 2 mm, and 2-5 mm. RESULTS: The conservative procedure was indicated 330 times, and 78 patients were re-operated for insufficiently free margins. The conservative procedure was completed 311 times, and mastectomy was done as the final procedure in 19 cases. Positive resection line was found 10 times. Distance up to 2 mm occurred 12 times and 25 mm 56 times. In all re-operated patients, presence of malignant cells in the re-excised tissue was found 31 times (39.7%). Repeated surgery for positive line, i.e. tumour present in the resection line, was done 10 times while malignant cells were found in all patients; for the distance up 2 mm, repeated surgery was done 12 times and 3 cases were positive (25%). For the distance of 2-5 mm, repeated excision occurred 56 times and 18 cases were positive, i.e. 32.1%. CONCLUSION: For the resection line "no tumour in contact with ink", presence of malignant cells in breast tissue must be expected in one third of the cases.Key words: breast carcinoma - conservative surgery - residual malignant cells.

[Clinical and Functional Importance of Selected CASP8 and CASP9 Polymorphisms in Breast Carcinoma]. / Klinický a funkcní význam vybraných polymorfizmu CASP8 a CASP9 u karcinomu prsu.

BACKGROUND: Caspase-8 and caspase-9 (encoded by CASP8 and CASP9) are executive caspases of programmed cell death (apoptosis). Dysregulation of apoptosis plays an important role in cancer development, progression, and resistance to anticancer therapy. The goal of this work was to evaluate potential associations between polymorphisms in CASP8 and CASP9, previously linked to breast cancer risk, and the transcript levels of these genes (including their alternative anti-apoptotic variants) in tumor tissues and the clinical characteristics of the patients. MATERIAL AND METHODS: Sanger sequencing, high resolution melting (HRM) analysis, and allelic discrimination were used to identify polymorphisms in DNA samples isolated from tumor tissues and peripheral blood lymphocytes of 60 breast carcinoma patients. Total transcript levels of CASP8 and CASP9, and levels of alternative splicing variants CASP8L and CASP9B, were quantified by real-time PCR in tumor tissues. Clinically interesting associations were validated in DNA from lymphocytes of 615 breast carcinoma patients. RESULTS: A haplotype in CASP9 composed of three polymorphisms rs4645978-rs2020903-rs4646034 was significantly associated with CASP9 expression in tumors, with the expression of the progesterone receptor and ERBB2, and with the TNBC subtype of breast carcinoma in the validation study. The associations between the rs3834129 polymorphism in CASP8 and stage of disease, rs6435074 with grade, expression of estrogen receptor and ERBB2, and rs6723097 with ERBB2 expression have not yet been validated. However, rs6723097 was associated with disease-free survival in patients treated with hormonal therapy. CONCLUSION: This study reveals a previously unknown and presumably functional (in silico) association between a haplotype in CASP9 and molecular and clinical phenotypes of breast carcinoma. The potential clinical utility of this association for prognostication of breast carcinoma should be evaluated by independent studies.Key words: breast carcinoma - caspases - polymorphisms - functional - clinical - importanceThis work was supported by grant of the CU Grant Agency No. 1444313, and grant of the Internal Grant Agency of the Czech Ministry of Health No. 15-25618A.The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 3. 3. 2016Accepted: 26. 10. 2016.

[Risk factors for anastomotic leakage following rectal resection - multicenter study]. / Rizikové faktory anastomotické insuficience po resekcích konecníku - Multicentrická studie.

INTRODUCTION: Anastomotic insufficiency (anastomotic leakage) is one of the most serious complications of the sphincter-saving rectal resections, with significant impact on patient morbidity and mortality. The risk rate of anastomotic leakage may be influenced by local anatomic conditions - tumour localisation and stage, possible technical problems in anastomosis construction (ischaemia, anastomosis under tension), and by complex factors associated with the patient - malnutrition, obesity, smoking, corticosteroid therapy and preoperative chemoradiation. MATERIAL AND METHODS: All sphincter-saving rectal resections that were performed between September 2011 and April 2014 in three centres of colorectal surgery, i.e. at Atlas Hospital in Zlín, the Czech Republic, and at Kosice-Saca Hospital and Dérers University Hospital in Bratislava, Slovakia, were included in the present multicentric prospective study. The incidence of anastomotic leakage in laparoscopic and open surgery was compared and the risk factors resulting in leakage occurrence were analyzed. RESULTS: Anastomotic leakage developed in 12 (10.9%) out of the total number of 110 patients. In the laparoscopic group (58 patients), the insufficiency occurred 4x (6.9%), in the 17 converted patients 3x (17.6%), and in the open surgery group (35 patients) the leakage occurred 5x (14.3%). There was no statistically significant difference between these groups. Nevertheless, patients with anastomotic leakage were only males (P=0.006), they had significantly lower pre-operative albumin levels (35.8 g/l vs. 38.3 g/l; P=0.03), as well as a lower pre-operative total protein level (60.8 g/l vs. 64.1 g/l; P=0.07), when compared to patients without insufficiency. Tumour distance from the anal verge in patients with anastomotic leakage was also significantly lower (10.8 cm vs. 12.8 cm; P=0.05). CONCLUSION: The following risk factors for anastomotic insufficiency after rectal surgery were identified: male gender, low pre-operative albumin and total protein levels, as well as decreasing tumour distance from the anal verge. The difference in the incidence of anastomotic insufficiency between laparoscopic and open surgery groups was not statistically significant.

Severe hidradenitis suppurativa.

INTRODUCTION: Hidradenitis suppurativa is a chronic, recurrent inflammatory disease causing significant changes and damage to skin. Predilection sites are the axilla and the anogenital region. Chronic and severe forms of the diseases may cause both physical and psychological injury to the patient. PATIENTS: We present the cases of two female patients with severe hidradenitis suppurativa in the axillae and in the anogenital region. The patients had been unsuccessfully treated for eight and four years respectively with antibiotics and by limited surgery. Different methods of closing the defects following radical surgical excision (local flap reconstruction, healing by granulation) had to be used with respect to the extent of the disease and the site of involved skin. CONCLUSION: Radical wide excision of the skin area involved is the only appropriate surgical procedure which prevents recurrence of the disease. Selection of the therapeutic method must be done very carefully with respect to the individual characteristics of the disease and the patients attitude to therapy.

[Specialization in oncosurgery is not against the surgeons best interest]. / Specializace v onkochirurgii není proti zájmum chirurgu

An analysis of the current situation in the surgical treatment of solid malignant tumors in the Czech Republic demonstrates the need to impose a concept of oncosurgical care, which would lead to a steady improvement in the quality of care provided by surgeons in oncosurgery. The primary aim is that surgery plays an appropriate role in the complex care of oncology patients and that surgeons become equal partners to radiation and internal oncologists in the determination of diagnostic - therapeutic plans and in other decision-making processes. This aim is not possible without increasing the qualification of surgeons in oncosurgery. Our more than ten year effort culminated in 2011 with the introduction of the specialized field of oncosurgery into the postgradual education of surgeons; and as such, similarly to most other developed countries, provided the official opportunity to educate surgeons in the field of oncology. Other important tasks which would contribute to increasing the quality of oncosurgery include rational concentration of oncosurgical operations to a smaller number of surgical departments, where it is necessary to ensure both the improvement of surgeon qualification by way of oncosurgical specialization, as well as adequate material and financial support for complex oncosurgical procedures.

[Continuing progress in withdrawal of axillary dissection in early stage breast cancer]. / Dalsí postupný ústup od axilární disekce u casného karcinomu prsu.

For a long period of time, axillary dissection represented a standard approach for axillary node management in the case of sentinel node biopsy positivity during early stage breast cancer treatment. In recent years, there has been a trend to highlight the morbidity of such an axillary procedure considering longterm survival of early stage breast cancer patients. Two big trials, AMAROS and Z0011, were initiated to answer the question whether axillary dissection should be performed in the case of positivity of axillary sentinel node considering the fact that more than 70% of these patients will have no metastasis found during the axillary dissection and such a procedure only increases the morbidity of the surgery. Considering the results of the above mentioned trials, axillary dissection may be avoided in the case of fulfilling of inclusion criteria of these trials without any impact on the patient survival. IBCSG 23- 01 study brought similar conclusion in the case of micrometastasis in axillary sentinel node.

[Is thyroid and parathyroid surgery safe? Is it suitable for one-day surgery?]. / Je chirurgie stítné zlázy a prístítných telísek opravdu bezpecná? Je vhodná pro jednodenní chirurgii?

INTRODUCTION: Thyroid and parathyroid surgery is regarded as a safe procedure with minimal complications, especially in high-volume centres. This fact increases the demand to perform thyroid surgery as an outpatient procedure or as a short-stay procedure in selected patients. MATERIAL AND METHODS: From 1995 to 2012, 5346 patients underwent thyroid surgery in the surgical ward of the Atlas Hospital. In a retrospective study we focused on complications that have occurred since 2008 in 1943 patients, especially postoperative hematoma and recurrent nerve palsy, comparing their number with literary data. RESULTS: Postoperative hematoma was diagnosed and revised in 22 cases, that is, in 1.1%. Potentially life-threatening postoperative hematoma, however, occurred also as late as 24 hours after surgery. All these cases were evaluated as emergency situations requiring urgent surgical revision. Definitive unilateral recurrent nerve palsy was diagnosed 15 times, i.e. in 0.77% of patients with complications, and, out of 2633 cases of "nerve at risk", in 0. 56%. Death has occurred in only two patients since 1995. Both of them were elderly and had serious comorbidities. All the other complications were not acute and could also have been managed in an outpatient procedure. CONCLUSION: The number of postoperative complications in the surgical ward of the Atlas Hospital in Zlín in thyroid surgery was similar to literature data, including the time of their occurrence. Outpatient and short-stay hospital procedure can be performed only in a strictly selected group of the patients.

[Minimally invasive video-assisted parathyroidectomy (MIVAP) using primary hyperparathyroidism therapy (pHPT)]. / Miniinvazivní videoasistovaná paratyreoidektomie (MIVAP) v terapii primární hyperparatyreózy (pHPT).

INTRODUCTION: Primary hyperparathyroidism (pHPT) is a general calcium, phosphate and bone metabolism malfunction due to increased secretion of the parathyroid hormone over a substantial period of time. Causal treatment is a surgical procedure - parathyroidectomy. MATERIAL AND METHODS: A retrospective study of patients who underwent surgery was conducted in the department of surgery at the Atlas Hospital in Zlín between 2005 and 2011. In this period, 2555 patients were operated on for thyroid and parathyroid gland disease. 182 of these patients (7.1%) had hyperparathyroidism. There were 80 standard parathyroidectomies, 82 MIVAPs and 20 MIRPs (minimally invasive radio-guided parathyroidectomy). RESULTS: In the study, 82 patients were operated on using the MIVAP technique. 78 (95.1%) had a parathyroid adenoma, 2 (2.4%) had hyperplasia, 2 (2.4%) had a standard body. Using the MIVAP technique, 75 parathyroid gland adenomas were found in 72 patients, 3 patients (3.6%) had a double adenoma. Conversion was performed in 10 patients (12.2%). During standard revision, an adenoma was found intraparenchymatously in 4 cases (4.9%), in 2 cases the adenoma was removed during standard revision. There was no permanent NRL paresis. 4 patients (4.9%) experienced temporary NLR paresis, MIVAP was successful in 72 patients (87.8%), 6 adenomas were removed during conversion; currently, all these patients have normal levels of calcium and parathyroid hormone. No parathyroid gland adenoma was found in 2 patients (2.4%), nor was it removed using persistent pHPT. 2 patients (2.4%) with hyperplasia are being monitored for their borderline calcium and parathyroid hormone levels. CONCLUSION: MIVAP is a complex endoscopic technique which can achieve 90% success rate in patients with the location of a parathyroid gland adenoma confirmed both by ultrasound and MIBI scanning.

Significance of the resection margin and risk factors for close or positive resection margin in patients undergoing breast-conserving surgery.

PURPOSE: While positive resection margin (RM) in women undergoing breast-conserving surgery (BCS) represents a clear indication for re-resection, there is no unequivocal recommendation regarding the extent of the clear RM. The aim of this study was to define the optimal extent of the RM and the risk factors for close or positive RM. METHODS: Patients scheduled for BCS had diagnosis confirmed before BCS (lumpectomy and quadrantectomy) by core biopsy. Sentinel lymph node biopsy followed BCS, and in case of positive findings axillary lymph node dissection followed. According to RM patients were categorized into 4 groups: 1) Patients with positive RM; 2) Clear RM < 2 mm; 3) Clear RM of 2-5 mm; and 4) RM > 5 mm. In the first 3 groups where re-resection was indicated, the presence of tumor cells in the re-resection specimen was determined. All patients were followed for local recurrence. RESULTS: 330 patients undergoing BCS were studied. Median follow up was 39.6 months (range 12-70). Lumpectomy was performed in 111 cases and quadrantectomy in 219. In 19 cases the final procedure was mastectomy due to the impossibility to achieve negative RM. In 78 cases re-resection followed the primary procedure due to close or positive RM. Clear RM was < 2 mm in 12 cases (15%), 2-5 mm in 56 (72%) and positive margin in 10 (13%). Positive re-resection specimen was detected in 31 cases (39.7%) (in 10 cases with positive RM after primary procedure, in 3 with negative margin < 2 mm and in 18 with 2-5 mm margin). The re-resection rate according to the location of the primary tumor was 77% (n=60) in the upper outer quadrant, 8% (n=6) in the lower outer quadrant, 6% (n=5) in the upper inner quadrant, 4% (n=3) in the lower inner quadrant, and 5% (n=4) in centrally located tumors. Multicentric/ multifocal tumor was diagnosed in 16 cases from which re-resection was indicated in 12 cases (75%). The number of re-resection according to tumor size was as follows: Tis 8 cases (30.7%), T1a none, T1b 14 (20.2%), T1c 34 (22.5%), T2 22 (28%). Re-resection was performed in 8 cases (31%) of ductal carcinoma in situ (DCIS), in 53 (22%) of ductal carcinoma, in 10 (37%) of lobular carcinoma, and in 7 (15%) of other histology. Five cases with local relapse were detected during follow up. CONCLUSION: The generally recommended clear RM of 1-5 mm is not sufficient because of the high number of positive specimens in the case of clear RM of 2-5 mm. The risk factors for close or positive RM are multicentric tumors and upper outer location of the primary tumor. Longer follow up will be needed to analyze local relapse rate according to RM status.