Combined analysis of the MF18-02/MF18-03 NEOSENTITURK studies: ypN-positive disease does not necessitate axillary lymph node dissection in patients with breast cancer with a good response to neoadjuvant chemotherapy as long as radiotherapy is provided.

BACKGROUND: The omission of axillary lymph node dissection (ALND) remains controversial for patients with residual axillary disease after neoadjuvant chemotherapy (NAC), regardless of the residual burden. This study evaluated the oncologic safety and factors associated with outcomes in patients with residual axillary disease. These patients were treated solely with sentinel lymph node biopsy (SLNB) or targeted axillary dissection (TAD), without ALND, after NAC. METHODS: A joint analysis of two different multicenter cohorts-the retrospective cohort registry MF18-02 and the prospective observational cohort registry MF18-03 (NCT04250129)-was conducted between January 2004 and August 2022. All patients received regional nodal irradiation. RESULTS: Five hundred and one patients with cT1-4, N1-3M0 disease who achieved a complete clinical response to NAC underwent either SLNB alone (n = 353) or TAD alone (n = 148). At a median follow-up of 42 months, axillary and locoregional recurrence rates were 0.4% (n = 2) and 0.8% (n = 4). No significant difference was found in disease-free survival (DFS) and disease-specific survival (DSS) rates between patients undergoing TAD alone versus SLNB alone, those with breast positive versus negative pathologic complete response, SLN methodology, total metastatic LN of one versus ≥2, or metastasis types as isolated tumor cells with micrometastases versus macrometastases. In the multivariate analysis, patients with nonluminal pathology were more likely to have a worse DFS and DSS, respectively, without an increased axillary recurrence. CONCLUSIONS: The omission of ALND can be safely considered for patients who achieve a complete clinical response after NAC, even if residual disease is detected by pathologic examination. Provided that adjuvant radiotherapy is administered, neither the SLNB method nor the number of excised LNs significantly affects oncologic outcomes.

Importance of Source Control in the Subgroup of Intra-Abdominal Infections for Septic Shock Patients: Analysis of 390 Cases.

Background: This study aimed to evaluate the epidemiology of septic shock (SS) associated with intraabdominal infections (IAI) as well as associated mortality and efficacy of early source control in a tertiary-care educational hospital. Methods: Patients who had SS with IAI and consulted by Infectious Diseases consultants between December 2013 and October 2022 during night shifts in our centre were analyzed retrospectively. Results: A total number of 390 patients were included. Overall, 30-day mortality was 42.5% on day 3, while day 14 and 30 mortality rates were 63.3% and 71.3%, respectively. Source control by surgical or percutaneous operation was performed in 123 of 390 cases (31.5%), and the mortality rate was significantly lower in cases that were performed source control at any time during SS (65/123-52.8% vs 213/267-79.8%, p<0.001). In 44 of 123 cases (35.7%), source control was performed during the first 12 hours, and mortality was significantly lower in this group versus others (24/44-54.5% vs 254/346-73.4%, p=0.009). On the other hand, female gender (p<0.001, odds ratio(OR)= 2.943, 95%CI=1.714-5.054), diabetes mellitus (p= 0.014, OR=2.284, 95%CI=1.179-4.424), carbapenem-resistant Gram-negative etiology (p=0.011, OR=4.386, 95%CI=1.398-13.759), SOFA≥10 (p<0.001, OR=3.036, 95%CI=1.802-5.114), lactate >3 mg/dl (p<0.001, OR=2.764, 95%CI=1.562-4.891) and lack of source control (p=0.001, OR=2.796, 95%CI=1.523-5.133) were significantly associated with 30-day mortality in logistic regression analysis. Conclusion: Source control has a vital importance in terms of mortality rates for IAI-related septic shock patients. Our study underscores the need for additional research, as the present analysis indicates that early source control does not manifest as a protective factor in logistic regression.

Radiological and clinicopathological findings of breast cancer during the COVID-19 pandemic: a comparative study with the pre-pandemic era.

PURPOSE: The diagnosis and surgical treatment delays that occurred during the coronavirus disease-2019- (COVID-19) pandemic may have affected breast cancer presentation. This study aimed to determine whether there was a difference in the clinicopathological characteristics of breast cancers during the pandemic by comparing them with similar cases from the previous year. The study also aimed to determine the radiological findings of breast cancers during the pandemic. METHODS: A retrospective review was made of patients who underwent surgery for breast cancer between March 11, 2020, and December 11, 2020 (the pandemic group). These patients were compared with similar patients from the previous year (the pre-pandemic group). The postoperative histopathology results of both groups were compared, and the preoperative radiological findings of the pandemic group were defined. RESULTS: There were 71 patients in the pandemic group and 219 patients in the pre-pandemic group. The tumor size was significantly greater, lymph node involvement was more frequent, and waiting time for surgery was longer in the pandemic group (P < 0.001, P = 0.044, P = 0.001, respectively). There was no significant difference between the groups in respect of in situ/invasive tumor distribution, histological type and histological grade of tumor, the presence of lymphovascular/perineural invasion, multifocal/multicentric focus, and Breast Imaging Reporting and Data System Classification (P > 0.15). The radiologic findings of breast cancer during the pandemic typically showed characteristics of malignancy. CONCLUSION: Patients diagnosed with breast cancer during the COVID-19 pandemic had larger tumor sizes, more frequent lymph node involvement and longer waiting time for surgical treatment. Screening programs should be continued as soon as possible by taking necessary precautions.

The Role of Primary Surgery in De Novo Metastatic Breast Carcinoma.

Approximately 6-10% of all breast carcinoma is metastatic at diagnosis, termed de novo metastatic breast carcinoma (dnMBC). Systemic therapy remains the first line of treatment in dnMBC, but there is growing evidence that adjuvant locoregional treatment (LRT) of the primary tumor increases progression-free and overall survival (OS). Although selection bias may exist, real-world data from nearly half a million patients show that patients are undergoing primary tumor removal because of the survival benefit. The main question for the advocates for LRT in this patient population is not whether primary surgery is beneficial in dnMBC patients, but rather who is a good candidate for it. Oligometastatic disease (OMD) is a distinct subset of dnMBC that affects a limited number of organs. A better OS can be achieved with LRT in breast cancer patients, especially in those with OMD, bone only, or favorable subtypes. Though there is currently no consensus among breast care specialists on how to treat dnMBC patients, primary surgery for dnMBC should be taken into consideration for a subset of patients following an extensive multidisciplinary discussion.

Effects of Body Mass Index Changes In Pediatric Kidney Transplant Patients.

BACKGROUND: The negative effects of pretransplant obesity and post-transplant body mass index (BMI) increase on graft survival have been reported in recent years. The aim of this study is to evaluate the effects of BMI changes on post-transplant graft function, lipid profile, and blood pressure. METHODS: The study included 133 pediatric patients transplanted between 1994 and 2019 in Ege University. BMI Z-scores (BMIZs) were calculated according to age and sex before and after transplantation using the World Health Organization criteria. Patients with BMIZs >+1 standard deviation (SD) were defined as overweight, and those with BMIZs >+2 SD were defined as obese: Group 1: Obese or overweight before transplantation; Group 2: Thin or normal weight before and 2 years after transplantation; and Group 3: Thin or normal weight before transplantation and obese or overweight 2 years after transplantation. RESULTS: At the time of transplantation 8% of the patients were overweight, and 1% were obese. Overweight and obesity statistically significantly increased (31.6%) 2 years after renal transplantation (P = .001). Obese and overweight patients have lower high-density lipoprotein levels and were younger at the time of transplantation. Graft functions, lipid levels, and blood glucose levels of the groups were similar (P > .05). The only significant difference between the groups was that Group 1 patients were younger than Group 2. CONCLUSIONS: Obesity develops at a significant rate in pediatric patients after renal transplantation. In this study, we could not demonstrate negative effects of obesity and being overweight in terms of post-transplant graft function, lipid profile, blood glucose, and blood pressure.

Is Serum Magnesium Level Associated With Serum Lipid Levels in Kidney Transplant Recipients?

BACKGROUND: Magnesium (Mg) is key in diabetes mellitus, hyperlipidemia, and cardiovascular disease. METHODS: This is a retrospective cross-sectional study including 103 kidney transplant recipients. Patients aged under 18 years, patients treated with Mg supplementation, antihyperlipidemic agents, or diuretics, and patients with active infection or malignancy were not enrolled. Patients were divided into 2 groups according to median serum Mg level. The atherogenic index of plasma was calculated by a logarithmic transformation of the number acquired by dividing the molar concentrations of serum triglyceride by high-density lipoprotein value. RESULTS: The mean serum Mg level was 1.91 ± 0.28 mg/dL. Six patients (5.8%) had hypomagnesemia (Mg <1.5 mg/dL), and 2 (1.9%) had hypermagnesemia (Mg >2.6 mg/dL). Serum Mg level was negatively correlated with body mass index, estimated glomerular filtration rate (eGFR), and tacrolimus trough level and positively correlated with levels of phosphorus, total cholesterol, and low-density lipoprotein (LDL-C). There was no correlation between serum Mg and triglyceride, high-density lipoprotein, atherogenic index of plasma, and cyclosporin A trough level. Patients with Mg >1.87 mg/dL had lower eGFR, tacrolimus, and cyclosporin A trough level and higher total cholesterol and LDL-C compared to those with Mg ≤1.87 mg/dL. In adjusted ordinal analysis, eGFR (hazard ratio (HR): 0.981, 95% CI 0.964-0.999, P = .036) and total cholesterol (HR: 1.015, 95% CI 1.004-1.027, P = .008) were independently associated with serum Mg. In multivariate linear regression analysis, serum Mg level was independently associated with LDL-C (ß = .296, t = 3.079, P = .003) and total cholesterol (ß = .295, t = 3.075, P = .003). CONCLUSION: Serum Mg level may have an important impact on dyslipidemia in kidney transplant recipients.

Role of Systemic Inflammatory Markers in Pediatric Kidney Transplantation.

BACKGROUND: Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), systemic immune-inflammation index (SII = N × P/L), and neutrophil percentage-albumin ratio (NPAR) have become accepted markers of inflammation in recent years. These indices are used as indicators of disease activity, mortality, and morbidity in many diseases. This study evaluated the relationship between inflammatory indices and graft function in pediatric kidney transplant recipients. METHODS: Medical records of pediatric patients who underwent kidney transplantation at Ege University between 1995 and 2020 were reviewed retrospectively. Demographic, clinical, and laboratory data were recorded during the third month, first year, and fifth year of transplantation and at the last visit. RESULTS: The median age of the 119 patients (60 boys/59 girls) at the time of transplantation was 154 months, and the median follow-up period was 101 months. According to Spearman correlation analysis, patients' final creatinine levels were positively correlated with NLR (r = 0.319), PLR (r = 0.219), SII (r = 0.214), and NPAR (r = 0.347) of the last visit; final estimate glomerular filtration rate levels were negatively correlated with NLR (P = .010, r = -0.250) and NPAR (P = .004, r = -0.277). The median NPAR of the patients with chronic allograft dysfunction at the last visit was found to be statistically significantly higher than without (P = .032). CONCLUSION: NLR, PLR, SII, and NPAR values are correlated with creatinine levels after 5 years of kidney transplantation. The NPAR and final creatinine levels had the highest correlation coefficient among these inflammatory markers. These results suggest that inflammatory markers, especially NPAR, may be a candidate to be an indicator of ongoing inflammation in the graft.

Functional outcomes of intersphincteric resection in low rectal tumors.

Objectives: Currently, sphincter-saving procedures are increasingly performed in the treatment of low rectal cancers. This study aimed to evaluate the outcomes of patients who underwent intersphincteric resection. Material and Methods: This was a single-center, retrospective, cross-sectional study. We evaluated the electronic data files of 29 patients who had intersphincteric resections at our institute between 2008 and 2018. Bowel function outcomes were assessed prospectively using Wexner incontinence score. Histopathological, surgical and functional outcomes were analyzed. Results: Mean age of nine female and 20 male patients included in the study was 55.8 ± 12.8 (30-76) years. A tumor-free surgical margin was achieved in all patients. Anastomotic leakage was detected in two patients. Mean Wexner incontinence score of 20 patients who still had functional anastomosis was 8.35, whereas 65% of the patients (n= 13) had a good continence status. There was no relationship between the continence status and sex, tumor distance from anal verge, T stage, distal surgical margin, and lymph node involvement. Twenty-one patients underwent primary coloanal anastomosis and eight patients underwent two-stage coloanal anastomosis. Conclusion: In the treatment of distal rectal cancer, adequate oncological surgery and relatively acceptable functional outcomes can be obtained with intersphincteric resection technique in suitable patients.

Improving the quality of operation notes: Effect of using proforma, audit and education sessions.

BACKGROUND: Both from a medical and legal point of view, the quality of operative notes are important. In this study we hypothesized that the quality of operation notes could be improved by audit, education session and using a proforma. METHODS: A total of 150 operation notes were audited for compliance with the Royal College of Surgeons guidelines. Results were announced in-clinic training session and guidelines were discussed. An aide-memoire containing guideline parameters placed in the operating theaters. After eight months, operation reports were re-audited on an equal number of patients. An operative note proforma was developed and third audit was carried out. The results of each audit were compared. RESULTS: In the first audit, it was found that fourteen parameters were written with more than 90% accuracy. The first audit revealed seven poor areas in documentation: time of operation (0%), identification of emergency/elective procedure (0%), identification of any prosthesis or devices used (65.3%), details of closure technique (36.6%), name of anesthesiologist (0%), patient position (1.3%), and amount of bleeding (0%). In the second audit there was an incomplete, but significant improvement in these seven parameters (28%, 28.6%, 82%, 75.3%, 31.3%, 32%, and 34% respectively). Following introduction of the proforma; third audit cycle demonstrated a clear improvement in operation note documentation with at least 80% compliance in all parameters. CONCLUSION: This study revealed that the accuracy of the operating room documents can be improved through audits, education of surgeon and using proformas. The use of proforma provides much better results.