The prognostic role of tumor size in early breast cancer in the era of molecular biology.

BACKGROUND: The prognosis of early breast cancer (EBC) depends on patient and tumor characteristics. The association between tumor size, the largest diameter in TNM staging, and prognosis is well recognized. According to TNM, tumors classified as T2, could have very different volumes; e.g. a tumor of 2.1 cm has a volume of 4500 mm3, while a tumor of 4.9 cm has a volume of 60.000 mm3 even belonging to the same class. The aim of the study is to establish if the prognostic role of tumor size, expressed as diameter and volume, has been overshadowed by other factors. METHODS: The primary objective is to evaluate the association between tumor dimensions and overall survival (OS) / disease free survival (DFS), in our institution from January 1st 2005 to September 30th 2013 in a surgical T1-T2 population. Volume was evaluated with the measurement of three half-diameters of the tumor (a, b and c), and calculated using the following formula: 4/3π x a x b x c. RESULTS: 341 patients with T1-T2 EBC were included. 86.5% were treated with conservative surgery. 85.1% had a Luminal subtype, 9.1% were Triple negative and 7.4% were HER2 positive. Median volume was 942 mm3 (range 0.52-31.651.2). 44 patients (12.9%) relapsed and 23 patients died. With a median follow-up of 6.5 years, the univariate analysis for DFS showed an association between age, tumor size, volume, histological grading and molecular subtype. The multivariate analysis confirmed the statistically significant association only for molecular subtype (p 0.005), with a worse prognosis for Triple negative and HER2 positive subtypes compared with Luminal (HR: 2.65; 95%CI: 1.34-5.22). Likewise for OS, an association was shown by the multivariate analysis solely for molecular subtype (HER2 and Triple negative vs. Luminal. HR: 2.83; 95% CI:1.46-5.49; p 0.002). CONCLUSIONS: In our study, the only parameter that strongly influences survival is molecular subtype. These findings encourage clinicians to choose adjuvant treatment not based on dimensional criteria but on biological features.

Role of patient and tumor characteristics in sentinel lymph node metastasis in patients with luminal early breast cancer: an observational study.

Predicting the risk of sentinel lymph node (SLN) metastasis is important for clinical decision-making in the setting of early breast cancer (EBC). This study is aimed to identify tumor and patient characteristics that influenced the SLN metastatic involvement, with a focus on luminal subtypes. An observational study including women treated for EBC from 2005 to 2013 was conducted. Regression analyses were used to assess the association between SLN metastasis and age, menopausal status, tumor size, histological grading, presence of extensive "in situ" carcinoma components, lymphovascular invasion (LVI), and expression of Ki-67, hormone receptors, and HER2. Of 345 women, 84 (24.3 %) had at least one SLN metastasis; 63.1 % were macrometastases. Among all patients, 31.6 % exhibited LVI. In univariate analyses, tumor size, histological grade, and LVI were associated with SLN metastasis. The multivariate model confirmed only the association between LVI and SLN status (OR 3.27, 95 % CI 1.85-5.68; p < 0.0001). Luminal subtypes were detected in 86.1 % of women. In this subgroup, the multivariate model confirmed a significant relationship between LVI and SLN status (OR 3.47, 95 % CI 1.90-6.33; p < 0.0001). Since a proper histopathological assessment of LVI is not possible prior to surgery, this factor cannot be used to guide decisions on performing SLN biopsies. Nevertheless, when a SLN biopsy is refused or contraindicated, an LVI assessment on an excisional biopsy of the tumor could facilitate prognosis determination and treatment management.

[Early diagnosis in acute mesenteric ischemia. Case series and clinical review]. / Diagnosi precoce nell'ischemia mesenterica acuta. Casistica e revisione clinica.

The AA report on 12 cases of intestinal infarction for acute mesenteric ischemia (IMA) in critical patients observed in the last 2 years. In this work some clinical data, blood tests and strumental considerations are described. IMA is a vascular emergency with severe prognosis and high rate morbidity and mortality, often correlated to a diagnostic delay. The discrepancy between symptoms and clinical objectivity must suggest the suspect, especially in patients with cardiac pathology, short lasting diarrhoea, bowel hemorrhage or only abdominal pain rebel to the analgesics; with the laboratory indexes and strumental data it can be carried out an early diagnosis and then begin the more opportune therapeutical treatment. The increase of blood sugar together to the triad leucocytosis--haemoconcentration and metabolic acidosis, in previously non diabetic patients, confirm the suspect of IMA in the very initial phases of this pathology.

[Acute mesenteric ischemia. Principles of treatment and surgical approach]. / Ischemia mesenterica acuta. Principi di trattamento e approccio chirurgico.

The AA report some considerations on the treatment and surgical approach during acute mesenteric ischemia (IMA) focusing some indications for a timely and suitable therapeutic approach. In the last 2 years, they treated 12 cases of IMA in critical patients. Early identification allows avoiding advanced phases of the intestinal infarct/bowel necrosis; in this phase the multidisciplinary approach for the hemodynamic stabilization is a priority, together with rianimatory support and surgery operation. The preservation of the intestinal vitality is essential to avoid the need of bowel resections or at least a major one. A suitable treatment permits a better survival and improvement of the quality of life. Surgical timing requires the intervention within 12 hours since the beginning of the symptoms to be more efficacious.

[Bouveret's syndrome: a rare clinical variant of gallstone ileus]. / Sindrome di Bouveret: rara variante clinica dell'ileo biliare.

Bouveret's syndrome is a rare complication of gallstone disease characterized by gastric outlet obstruction due to impaction of single or multiple gallstones which have migrated through a bilio-enteric fistula. The main symptoms are nausea, vomiting and epigastric pain. The diagnosis is achieved by plain film of the abdomen, ultrasonography and CT scan, which reveal aerobilia (an indirect sign of bilio-enteric fistula), and the obstructing gallstone. The treatment of this condition requires removal of the stone through an endoscopic or surgical approach, and possible cholecystectomy with closure of the fistula. The Authors report a case of Bouveret's syndrome in an 86-year-old female patient who underwent successful surgical treatment.