Adult Onset Still's Disease and Radiotherapy treatment for breast cancer: Case report about management of this rare association and literature review.

AIM: This manuscript focuses on the first experience in literature of a patient with a complicated Adult Onset Still's Disease-related heart failure who thereafter underwent adjuvant radiotherapy for left breast cancer. BACKGROUND: AOSD is a rare autoimmune inflammation-related disease, in which life-threatening pulmonary and cardiac complications can occur. In literature, AOSD is often associated with cancer, as paraneoplastic syndrome, but there are few data about primary AOSD and management of oncological therapies. MATERIALS AND METHODS: A patient who needed adjuvant breast cancer radiotherapy underwent tumour board evaluation to define feasibility of an RT in a patient with of a history of a heart life-threatening complication 2 years before AOSD. Results of the review were discussed by a multidisciplinary panel of experts that chose the type of surgery, radiotherapy and monitoring of patient. RESULTS: Literature review confirmed association of AOSD with BC in some pts and uniqueness of this treatment management experience. Patient underwent RT according to schedule of 40.05/2.67 Gy/fx on residual left breast and 10/2 Gy/fx on tumour bed with the gating technique. The panel chose to keep immunosuppressive therapy with anakinra. No complications were observed at clinical, ECG and laboratory examinations. Maximum toxicity was G2 skin. At first follow up AOSD signs of flare were negative. CONCLUSION: In conclusion, when oncological treatments, especially radiotherapy, are mandatory for AOSD pts, multidisciplinary management and tailored monitoring are necessary to avoid acute adverse effects and allow pts to complete therapies.

Young Women with Early-Stage Breast Cancer Treated with Upfront Surgery: Overview of Oncological Outcomes.

Background: Breast cancer in young women aged < 40 years is rare and often aggressive with less favorable survival rates. The lack of systematic screening, later stage at diagnosis, and a more aggressive disease biology may all contribute to their poor prognosis. Data on the best management remain conflicting, especially those regarding surgical management, either breast-conserving or mastectomy. To our knowledge, there are limited studies surrounding the treatment of young women with early breast cancer, and this analysis evaluated the oncological outcomes for those patients who underwent surgery upfront. Methods: We conducted a retrospective study including 130 young women with early breast cancer from a total of 373 consecutive patients treated with upfront surgery between January 2016 and December 2021 at our institution. Local recurrence-free survival (LR-FS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) were evaluated. Results: The median follow-up was 61.1 months (range, 25-95). A total of 92 (70.8%) patients underwent breast-conserving surgery, while 38 (29.2%) patients underwent conservative mastectomy with immediate implant breast reconstruction. In total, 8 of 130 patients (6.2%) developed a local recurrence in the treated breast, an7 (5.4%) patients presented distant metastasis. Overall, two (1.6%) patients died due to breast cancer recurrence. Conclusions: The results of our study interestingly support breast-conserving surgery in young patients with early-stage breast cancer. While appropriate breast-conserving surgery can achieve favorable oncological outcomes and can always be considered a valid alternative to conservative mastectomy in upfront surgery, a younger age at diagnosis should never be used alone to choose the type of surgery.

Outcomes of Radiotherapy in Oligoprogressive Breast Cancer.

INTRODUCTION: Radiotherapy (RT) shows potential for improving local control in cases of oligoprogressive metastatic breast cancer (mBC). This retrospective analysis aims to evaluate the advantages of RT in such a clinical scenario. METHODS: We conducted a retrospective analysis including patients with mBC who received radiation therapy (RT) for up to three sites of oligoprogression while continuing systemic therapy. The study took place between January 2014 and December 2021. Our endpoints were progression-free survival after radiotherapy (PFS-AR), the rate of discontinuation of systemic therapy (RDT) at three months post-RT, and overall survival (OS). We used Cox regression analysis to perform multivariate analysis for PFS-AR. RESULTS: Fifty-nine patients met the inclusion criteria. The PFS-AR was 13 months (95% CI 8.5-18.8 months). At three months, the RDT was 3% (two patients). A significant difference in median PFS-AR was observed between patients in the first + second-line group and those in the subsequent line group (p = 0.03). In the multivariate analysis conducted for PFS-AR, the biologically effective dose (BED) with α/ß = 4 > 100 Gy emerged as the sole significant variable (p = 0.0017). The median overall survival (OS) was 24.4 months (95% CI 17-24.4 months). CONCLUSIONS: This study is the first report on the outcomes of radiotherapy in a cohort of over 50 patients with oligoprogressive metastatic breast cancer (mBC). Our findings emphasize the significant relationship between PFS-AR, the number of ongoing lines of systemic therapy, and the BED of radiotherapy.

An Innovative Scoring System to Select the Optimal Surgery in Breast Cancer after Neoadjuvant Chemotherapy.

INTRODUCTION: The selection of surgery post-neoadjuvant chemotherapy (NACT) is difficult and based on surgeons' expertise. The aim of this study was to create a post-NEoadjuvant Score System (pNESSy) to choose surgery, optimizing oncological and aesthetical outcomes. METHODS: Patients (stage I-III) underwent surgery post-NACT (breast-conserving surgery (BCS), oncoplastic surgery (OPS), and conservative mastectomy (CMR) were included. Data selected were BRCA mutation, ptosis, breast volume, radiological response, MRI, and mammography pre- and post-NACT prediction of excised breast area. pNESSy was created using the association between these data and surgery. Area under the curve (AUC) was assessed. Patients were divided into groups according to correspondence (G1) or discrepancy (G2) between score and surgery; oncological and aesthetic outcomes were analyzed. RESULTS: A total of 255 patients were included (118 BCS, 49 OPS, 88 CMR). pNESSy between 6.896-8.724 was predictive for BCS, 8.725-9.375 for OPS, and 9.376-14.245 for CMR; AUC was, respectively, 0.835, 0.766, and 0.825. G1 presented a lower incidence of involved margins (5-14.7%; p = 0.010), a better locoregional disease-free survival (98.8-88.9%; p < 0.001) and a better overall survival (96.1-86.5%; p = 0.017), and a better satisfaction with breasts (39.8-27.5%; p = 0.017) and physical wellbeing (93.5-73.6%; p = 0.001). CONCLUSION: A score system based on clinical and radiological features was created to select the optimal surgery post-NACT and improve oncological and aesthetic outcomes.

Prepectoral vs. Submuscular Immediate Breast Reconstruction in Patients Undergoing Mastectomy after Neoadjuvant Chemotherapy: Our Early Experience.

BACKGROUND: Conservative mastectomy with immediate prosthetic breast reconstruction (IPBR) is an oncologically accepted technique that offers improved esthetic results and patient quality of life. Traditionally, implants have been placed in a submuscular (SM) plane beneath the pectoralis major muscle (PMM). Recently, prepectoral (PP) placement of the prosthesis has been increasingly used in order to avoid morbidities related to manipulation of the PMM. The aim of this study was to compare outcomes of SM vs. PP IPBR after conservative mastectomy in patients with histologically proven breast cancer treated with neoadjuvant chemotherapy (NAC). METHODS: In this retrospective observational study, we analyzed two cohorts of patients that underwent mastectomy with IPBR after NAC in our institution from January 2018 to December 2021. Conservative mastectomy was performed in 146 of the 400 patients that underwent NAC during the study period. Patients were divided into two groups based on the positioning of implants: 56 SM versus 90 PP. RESULTS: The two cohorts were similar for age (mean age 42 and 44 years in the SM and PP group respectively) and follow-up (33 and 20 months, respectively). Mean operative time was 56 min shorter in the PP group (300 and 244 min in the SM and PP group). No significant differences were observed in overall major complication rates. Implant loss was observed in 1.78% of patients (1/56) in the SM group and 1.11% of patients (1/90) in PP group. No differences were observed between the two groups in local or regional recurrence. CONCLUSIONS: Our preliminary experience, which represents one of the largest series of patients undergoing PP-IPBR after NAC at a single institution documented in the literature, seems to confirm that PP-IPBR after NAC is a safe, reliable and effective alternative to traditional SM-IPBR with excellent esthetic and oncological outcomes; it is easy to perform, reduces operative time and minimizes complications related to manipulation of PPM. However, this promising results need to be confirmed in prospective trials with longer follow-up.

Sentinel Node Biopsy after Neoadjuvant Chemotherapy for Breast Cancer: Preliminary Experience with Clinically Node Negative Patients after Systemic Treatment.

Sentinel lymph node biopsy (SLNB) following neoadjuvant treatment (NACT) has been questioned by many studies that reported heterogeneous identification (IR) and false negative rates (FNR). As a result, some patients receive axillary lymph node dissection (ALND) regardless of response to NACT, leading to a potential overtreatment. To better assess reliability and clinical significance of SLNB status on ycN0 patients, we retrospectively analyzed oncological outcomes of 399 patients treated between January 2016 and December 2019 that were either cN0-ycN0 (219 patients) or cN1/2-ycN0 (180 patients). The Endpoints of our study were to assess, furthermore than IR: oncological outcomes as Overall Survival (OS); Distant Disease Free Survival (DDFS); and Regional Disease Free Survival (RDFS) according to SLNB status. SLN identification rate was 96.8% (98.2% in patients cN0-ycN0 and 95.2% in patients cN+-ycN0). A median number of three lymph nodes were identified and removed. Among cN0-ycN0 patients, 149 (68%) were confirmed ypN0(sn), whereas regarding cN1/2-ycN0 cases 86 (47.8%) confirmed an effective downstaging to ypN0. Three year OS, DDFS and RDFS were significantly related to SLNB positivity. Our data seemed to confirm SLNB feasibility following NACT in ycN0 patients, furthermore reinforcing its predictive role in a short observation timing.

GENERATOR Breast DataMart-The Novel Breast Cancer Data Discovery System for Research and Monitoring: Preliminary Results and Future Perspectives.

BACKGROUND: Artificial Intelligence (AI) is increasingly used for process management in daily life. In the medical field AI is becoming part of computerized systems to manage information and encourage the generation of evidence. Here we present the development of the application of AI to IT systems present in the hospital, for the creation of a DataMart for the management of clinical and research processes in the field of breast cancer. MATERIALS AND METHODS: A multidisciplinary team of radiation oncologists, epidemiologists, medical oncologists, breast surgeons, data scientists, and data management experts worked together to identify relevant data and sources located inside the hospital system. Combinations of open-source data science packages and industry solutions were used to design the target framework. To validate the DataMart directly on real-life cases, the working team defined tumoral pathology and clinical purposes of proof of concepts (PoCs). RESULTS: Data were classified into "Not organized, not 'ontologized' data", "Organized, not 'ontologized' data", and "Organized and 'ontologized' data". Archives of real-world data (RWD) identified were platform based on ontology, hospital data warehouse, PDF documents, and electronic reports. Data extraction was performed by direct connection with structured data or text-mining technology. Two PoCs were performed, by which waiting time interval for radiotherapy and performance index of breast unit were tested and resulted available. CONCLUSIONS: GENERATOR Breast DataMart was created for supporting breast cancer pathways of care. An AI-based process automatically extracts data from different sources and uses them for generating trend studies and clinical evidence. Further studies and more proof of concepts are needed to exploit all the potentials of this system.

The Assisi Think Tank Meeting Breast Large Database for Standardized Data Collection in Breast Cancer-ATTM.BLADE.

Background: During the 2016 Assisi Think Tank Meeting (ATTM) on breast cancer, the panel of experts proposed developing a validated system, based on rapid learning health care (RLHC) principles, to standardize inter-center data collection and promote personalized treatments for breast cancer. Material and Methods: The seven-step Breast LArge DatabasE (BLADE) project included data collection, analysis, application, and evaluation on a data-sharing platform. The multidisciplinary team developed a consensus-based ontology of validated variables with over 80% agreement. This English-language ontology constituted a breast cancer library with seven knowledge domains: baseline, primary systemic therapy, surgery, adjuvant systemic therapies, radiation therapy, follow-up, and toxicity. The library was uploaded to the BLADE domain. The safety of data encryption and preservation was tested according to General Data Protection Regulation (GDPR) guidelines on data from 15 clinical charts. The system was validated on 64 patients who had undergone post-mastectomy radiation therapy. In October 2018, the BLADE system was approved by the Ethical Committee of Fondazione Policlinico Gemelli IRCCS, Rome, Italy (Protocol No. 0043996/18). Results: From June 2016 to July 2019, the multidisciplinary team completed the work plan. An ontology of 218 validated variables was uploaded to the BLADE domain. The GDPR safety test confirmed encryption and data preservation (on 5000 random cases). All validation benchmarks were met. Conclusion:BLADE is a support system for follow-up and assessment of breast cancer care. To successfully develop and validate it as the first standardized data collection system, multidisciplinary collaboration was crucial in selecting its ontology and knowledge domains. BLADE is suitable for multi-center uploading of retrospective and prospective clinical data, as it ensures anonymity and data privacy.

Conservative treatment of a rare case of multifocal adenoid cystic carcinoma of the breast: case report and literature review.

BACKGROUND: Adenoid cystic carcinoma of the breast is a rare neoplasm accounting for 0.1% of all malignant breast tumors and presenting most commonly as a painful breast mass. Compared with the more common histological forms of breast cancer, it has a more favorable prognosis and lymph node involvement or distant metastases seldom occur. CASE REPORT: A unique case of multifocal adenoid cystic carcinoma of the breast presenting as a painful and well-defined lump and treated with conservative surgery with adjuvant radiotherapy is reported. CONCLUSIONS: There is no consensus on the optimal management of this disease. A breast-conserving approach may be recommended even if mastectomy has been traditionally the treatment of choice. Chemotherapy, radiation, and hormonal therapy have been infrequently used and so far have had no defined role in this kind of neoplasm. The authors found no other reports in the literature focusing on a conservative approach to multifocal adenoid cystic carcinoma.

The role of fine-needle aspiration performed with liquid-based cytology in the surgical management of thyroid lesions.

BACKGROUND: The aim of this retrospective study was to assess the accuracy and usefulness of cytological classification of fine-needle aspirates in determining the appropriate surgical treatment for thyroid lesions studied with conventional smears (CS) and liquid-based cytology (LBC) in a split-sample method. PATIENTS AND METHODS: A total of 353 patients were studied with both CS and LBC. The cytological diagnoses were classified according to the British Thyroid Association into 5 groups: Thy1, inadequate; Thy2, non-neoplastic or benign group including goiter, thyrocytic hyperplasia without nuclear atypia and thyroiditis; Thy3 or indeterminate/follicular proliferation, including follicular neoplasm not otherwise specified and oxyphilic follicular neoplasm; Thy4, suspicious for malignancy, including follicular lesion with nuclear pleomorphism; Thy5, diagnostic for malignancy including papillary carcinoma and medullary carcinoma. The efficacy of thyroid fine-needle aspiration processed by CS with LBC in a split-sample method was evaluated. RESULTS: Overall 164 patients were included in the Thy2, 97 in the Thy3, 49 in the Thy4, and 43 in the malignant Thy5 group. The percentage of unnecessary thyroidectomies decreased from 58.5 to 42% in our series. CONCLUSION: Our subclassification, according to the British Thyroid Association classification, attempts to reduce the number of Thy3 who undergo surgery. The comparison between the traditional management of thyroid lesions and our morphological categories with the use of CS and LBC together allows the number of unnecessary thyroidectomies to be reduced.

Diagnosis and Treatment of Bone Metastases in Breast Cancer: Radiotherapy, Local Approach and Systemic Therapy in a Guide for Clinicians.

The standard care for metastatic breast cancer (MBC) is systemic therapies with imbrication of focal treatment for symptoms. Recently, thanks to implementation of radiological and metabolic exams and development of new target therapies, oligometastatic and oligoprogressive settings are even more common-paving the way to a paradigm change of focal treatments role. In fact, according to immunophenotype, radiotherapy can be considered with radical intent in these settings of patients. The aim of this literature review is to analyze available clinical data on prognosis of bone metastases from breast cancer and benefits of available treatments for developing a practical guide for clinicians.

Oncotype DX Predictive Nomogram for Recurrence Score Output: The Novel System ADAPTED01 Based on Quantitative Immunochemistry Analysis.

PURPOSE: Oncotype DX (ODX) predicts breast cancer recurrence risk, guiding the choice of adjuvant treatment. In many countries, access to the test is not always available. We used correlation between phenotypical tumor characteristics, quantitative classical immunohistochemistry (IHC), and recurrence score (RS) assessed by ODX to develop a decision supporting system for clinical use. PATIENTS AND METHODS: Breast cancer patients who underwent ODX testing between 2014 and 2018 were retrospectively included in the study. The data selected for analysis were age, menopausal status, and pathologic and IHC features. IHC was performed with standardized quantitative methods. The data set was split into two subsets: 70% for the training set and 30% for the internal validation set. Statistically significant features were included in logistic models to predict RS ≤ 25 or ≤ 20. Another set was used for external validation to test reproducibility of prediction models. RESULTS: The internal set included 407 patients. Mean (range) age was 53.7 (31-80) years, and 222 patients (54.55%) were > 50 years old. ODX results showed 67 patients (16.6%) had RS between 0 and 10, 272 patients between 11 and 25 (66.8%), and 68 patients > 26 (16.6%). Logistic regression analysis showed that RS score (for threshold ≤ 25) was significantly associated with estrogen receptor (P = .004), progesterone receptor (P < .0001), and Ki-67 (P < .0001). Generalized linear regression resulted in a model that had an area under the receiver operating characteristic curve (AUC) of 92.2 (sensitivity 84.2%, specificity 80.1%) and that was well calibrated. The external validation set (183 patients) analysis confirmed the model performance, with an AUC of 82.3 and a positive predictive value of 91%. A nomogram was generated for further prospective evaluation to predict RS ≤ 25. CONCLUSION: RS was related to quantitative IHC in patients with RS ≤ 25, with a good performance of the statistical model in both internal and external validation. A nomogram for enhancing clinical approach in a cost-effective manner was developed. Prospective studies must test this application in clinical practice.

Shoulder girdle impairment in breast cancer survivors: the role of range of motion as predictive factor for dose distribution and clinical outcome.

BACKGROUND: Pain and functional impairment of the ipsilateral shoulder girdle in patients who underwent surgery and radiotherapy for breast cancer (BC) is a late complication reported in the literature. We analyze a correlation with dosimetric parameters and propose an algorithm for sparing strategies. METHODS: A total of 111 patients treated for BC were included in this observational analysis during follow-up protocol visits. Exclusion criteria were the presence of moderate or severe arthrosis history and/or rheumatologic diseases. All the patients had complete physical and multidimensional examinations during joint (physiatrist and radiotherapy oncology) follow-up visits. A scapula-humeral articulation (SHA) standardized contouring was performed retrospectively on Eclipse® treatment plans. A possible correlation between patients' characteristics, radiotherapy, and dosimetry analysis and functional impairment was investigated at statistical analysis. Results of analysis were summarized into a proposal of algorithm for sparing SHA. RESULTS: A total of 111 patients were selected during follow-up visits. Mean age of patients was 60 years (range 41-85 years). A total of 103 patients (93%) underwent conservative surgery, with 110 patients (99%) undergoing axilla surgery as well. Fifty-two patients (46.8%) presented a reduction of range of motion (ROM) abduction on the treated side at the observational analysis. Mean ROM abduction reduction was 13°06' (range 0°-100°). Disability of the Arm, Shoulder and Hand questionnaire (DASH) score results were excellent in 79 patients (71.2%), discrete in 15 patients (13.5%), good in 15 patients (13.5%), and sufficient in 2 patients (1.8%). Median EQD2 Dmax at SHA was 18 Gy (range 0.22-51.9 Gy) and median EQD2 mean dose at SHA was 2 Gy (range 0.04-24.32 Gy). Univariate analysis showed a linear correlation between DASH score and ROM of abduction of treated side (ρ=-0.7), ROM of abduction and ROM of flexion in ipsilateral arm (ρ=0.8), or ROM of abduction and ROM of flexion in contralateral arm (ρ=0.8). A statistically significant difference in ROM abduction between the 2 arms was found at χ2 test (P<0.05 at χ2 confidence interval = 95%). Cox linear regression analysis showed ROM abduction on treated arm as a predictive factor of DASH score (P<0.0001). Age (P<0.05), DASH score (P=0.006), and ROM abduction on treated arm (P=0.005) were found as independent predictive factors of mean dose at multivariate analysis. A mean dose higher than 7 Gy and ROM abduction reduction more than 30° were related to DASH score level reduction. CONCLUSIONS: This hypothesis-generating study introduces an algorithm to be validated for management of sparing SHA and improving quality of survivorship. ROM evaluation after surgery, early physiotherapy, standard contouring, and planning adaptation represent possible indications to preserve shoulder impairment. Further prospective studies are needed to discriminate impairment of surgery and radiotherapy in order to personalized therapeutic plan programs.

[Laparoscopic repair of incisional and ventral hernia]. / Trattamento laparoscopico delle ernie incisionali e ventrali della parete addominale.

The application of laparoscopic principles to ventral or incisional hernia repair has recently been shown to be a safe and effective alternative to open procedures. In this study we analyzed our recent experience with laparoscopic incisional-ventral hernia repair. The outcomes of 75 consecutive patients (January 2002 to July 2006) who underwent laparoscopic repair for incisional-ventral hernia were reviewed. Patient's demographics, hernia parameters, and intraoperative and postoperative data were collected. Of the 75 patients, 44 were females and 31 males. Mean age was 59.1 yrs (range 29-80 yrs). Mean BMI was 25.9 (range 19.4-36.7). Twenty-one patients had primary ventral hernias while 54 patients had an incisional hernia. Fifty-three patients had a single defect and 22 patients multiple defects. In 45 cases the incisional hernia was a primary hernia; in 4 cases it was a first recurrence; in 2 cases a 2nd recurrence; and in 3 cases a 3rd recurrence. The mean defect size was 52,7 cm2 (range 4-432). Laparoscopic hernia repair was successfully performed in 71 cases (94.7%). The mean mesh size was 211 cm2 (range 63-694). Mean operating time was 101 min (range 50-220 min). The mean hospital stay was 4.7 days. The postoperative morbidity rate was 14%. After a mean follow-up of 24.6 months (range 7-56) the recurrence rate was 7% (5/71). Laparoscopic repair of incisional-ventral hernias seems to be safe and effective. Medium-term outcomes were promising with a relatively low rate of conversion to open surgery, a low complication rate and a low risk of recurrence.

[Immediate and long-term results after laparoscopic primary ventral hernia repair]. / La chirurgia laparoscopica nelle ernie ventrali primitive della parete addominale: risultati immediati ed a distanza.

OBJECTIVE: Umbilical and epigastric hernias are relatively frequent amounting to about 10% of all primary hernias. The aim of this study was to evaluate the efficacy and safety of laparoscopic primary ventral hernia repair. MATERIAL AND METHODS: From January 2002 through July 2007 a total of 23 consecutive patients were treated by laparoscopy for primary ventral hernia. Main demographics, intraoperative and postoperative data were collected. RESULTS: There were 14 males and 9 females with a mean age of 53.1 yrs (range 28-70 yrs). Mean body mass index was 25.2 kg/m2 (range 19.4 - 35.2). Fifteen patients had an umbilical hernia, 6 patients had an epigastric hernia and 2 a Spigelian hernia. Mean defect size was 8,4 cm2 (range 1.7 - 81.6). Mean mesh size was 115.9 cm2 (range 62.8-310.8). Mean operating time was 76.1 min (range 50-130). Mean hospital stay was 3,4 days (range 2-8). The median postoperative pain score (evaluated by a visual analog scale - VAS) was 2 at day 1, 4 at day 3 and 1 at day 7. Morbidity rate was 4.3%. After a mean follow-up of 28.5 months none recurrences were observed. CONCLUSIONS: Our study confirmed the feasibility of laparoscopic repair in terms of postoperative morbidity and recurrence rate. Thus laparoscopic primary ventral hernia repair should be considered an effective alternative to open techniques.

Integrated breast cancer surgical treatment: novel aspects of minimally-invasive treatments.

The surgical management of breast cancer has been undergoing continuous and profound changes over the last 40 years. The evolution from aggressive and mutilating treatment to conservative approach has been long but constant, despite the controversies arising every time a new procedure came to light. Today, the esthetic satisfaction of breast cancer patients coupled with oncological safety is the goal of the modern breast surgeon. Breast-conserving surgery with adjuvant radiotherapy is considered the gold standard approach for patients with early stage breast cancer and the recent introduction of "oncoplastic techniques" has furtherly increased the use of breast-conserving procedures. Mastectomy still remains a valid surgical alternative in selected cases and is usually associated with immediate reconstructive procedures. New surgical procedures called "conservative mastectomies" are emerging as techniques that combine oncological safety and esthetic outcome by entirely removing the breast parenchyma sparing the breast skin and nipple-areola complex. Staging of the axilla has also gradually evolved toward less aggressive approaches with the adoption of sentinel node biopsy and new therapeutic strategies are emerging in patients with a pathological positivity in sentinel lymph node biopsy. The present special article will highlight the new surgical treatment options, which are more and more effective and respectful of breast cancer patients.

[Legal contentions in thyroid surgery. Kind of preoperative information to the patients]. / Problematiche medico-legale in chirurgia tiroidea. L'informazione preoperatoria al paziente.

The question of patients information and the achievement of an informed consent to medical and/or surgical treatment by the patient still represents one of the main issue of the medical profession, having greater importance nowadays in respect to the past regarding the relationship doctor-patient and to the diagnostic-therapeutic approach to the patient. Written informed consent is a pre requisite for surgical intervention as it provides the forum for the patient to appreciate implications of the procedure and the doctor to explain details and effects of the surgery. Patients refusal is, nowadays, according to the latest orientation of the Italian Supreme Court, the major limitation to medical or surgical intervention. For these reason we have thought better to propose a written form of informed consent regarding the thyroid surgery, which implies, more than other surgery's act, the exposition of the patient to adverse iatrogenic risks and as a consequence it can expose the surgeon to criminal or civil liabilities.

Update on the surgical management of breast cancer.

The surgical management of breast cancer has undergone continuous and profound changes over the last three decades. For patients with early stage breast cancer, breast-conserving surgery followed by radiation therapy has been definitively validated as a safe alternative to radical mastectomy, with similar survival rates, better cosmetic outcomes and acceptable rates of local recurrence. Thanks to the improvements in diagnostic work-up, as well as the wider diffusion of screening programs and efforts in patient and physician education, tumors are more often detected at an early stage, furtherly facilitating the widespread use of breast conserving techniques. Breast-conserving surgery has been introduced also in the treatment of patients with locally advanced tumors after tumor downsizing with preoperative chemotherapy, with acceptable rates of ipsilateral breast tumor recurrence. When performing breast-conserving surgery all efforts should be made to ensure negative surgical margins in order minimize the risk of ipsilateral breast tumor recurrence as they are associated with worse distant-disease-free and breast cancer- specific survival rates. The recent introduction of "oncoplastic techniques", that may allow more extensive excisions of the breast without compromising the cosmetic results, has furtherly increased the use of breast-conserving procedures. Mastectomy remains a valid surgical alternative in selected cases and is usually associated with immediate reconstructive procedures. Staging of the axilla has also gradually evolved toward less aggressive approaches with the adoption of sentinel node biopsy, but several controversies still remain about completion of axillary lymph node dissection in patients with a pathologic positivity in sentinel lymph node biopsy. The present work will highlight the benefits and unresolved issues of the different surgical treatment options in breast cancer and axillary treatment.

Immunohistochemical evaluation of inflammatory and proliferative markers in adjacent normal thyroid tissue in patients undergoing total thyroidectomy: results of a preliminary study.

BACKGROUND: Total thyroidectomy is the treatment of choice in the majority of thyroid malignancies, preventing the risk of reoperative surgery due to recurrences. In order to assess the usefulness of such an approach, expression levels of inflammatory and proliferative markers were evaluated immunohistochemically in non-lesional adjacent thyroid tissues from a group of patients who underwent total thyroidectomy for different thyroid diseases. METHODS: Nineteen consecutive patients treated by total thyroidectomy for different thyroid diseases entered the study. IL-6Rb gp130 component of the IL-6 cytokine family members receptor complexes, STAT3 cytokine signalling transduction and transcription activation factor, p53 as tumour suppressor and CK19 cytokeratin as proliferation marker were analyzed in non-lesional thyroid tissues. RESULTS: Gp 130 expression was detected in all tissue samples with a scattered distribution while STAT3 and p53 positivity was observed in 17 out of 19 patients with a prevailing cytoplasmic localization. Cytokeratin 19 positivity was found in patients with papillary carcinoma, in one case of follicular adenoma, 3 multinodular goiters and one Basedow disease. CONCLUSION: Based on the results of this preliminary study, it may be concluded that the presence of a persisting cytokine-mediated activation associated with cytoplasmic localization of p53 is frequently observed in different thyroid diseases. Such a process seems to occur in the thyroid gland as a whole. Moreover, STAT3 activation as well as mutant p53 are risk factors for the development of neoplastic diseases. Total thyroidectomy may be supported as an adequate therapeutic approach for all the patients in whom overexpression of cytokine-dependent markers is detected.