Risk Factors Associated to Residual Tumor in Re-excision for Positive Margins in Breast Conservative Surgery.

BACKGROUND: Breast conservative surgery (BCS) is an adequate treatment for patients with early breast cancer. Local recurrence is associated with diverse factors. Our objective was to evaluate risk factors associated with finding residual tumor in patients with positive margins in BCS. METHODS: Observational retrospective study, including patients diagnosed with breast cancer undergoing BCS between 2000 and 2016. Clinicopathological and treatment variables were collected. Main outcome was the finding of residual tumor on re-excision. Positive margins were defined as tumor present on ink. RESULTS: Three hundred and six patients underwent BCS. Mean age was 57 ± 12.2 years. Positive margins were found in 84 (27.4%) patients, 15 (4.9%) had unknown margin status, and 207 (67.6%) had negative margins. Seventy-eight patients from the positive margin group and 23 patients from the unknown/negative margin group were reintervened. Residual tumor was present in 41% of patients with positive margins and in 45% of patients with negative margins (P = .192). In univariate analysis, overweight (P = .04) and positive axillary lymph nodes (P = .02) were associated with residual tumor on re-excision. In multivariate analysis, postmenopausal status was a protective factor (HR .047, P = .30). Mean follow-up was 58.4 months and mean local recurrence-free survival (LRFS) was 56.4 months (.1-203.2), with no difference regarding margin status or residual tumor. DISCUSSION: Postmenopausal status was associated with a decreased rate of residual tumor in patients with positive margins. The presence of residual tumor on re-excision was not associated with a lower LRFS. These factors must be considered when positive margins are present in BCS.

Does laparoscopic reoperation yield symptomatic improvements similar to those of primary laparoscopic Heller myotomy in achalasia patients?

BACKGROUND: Laparoscopic Heller myotomy fails in approximately 3.5% to 15% of patients. Evidence of successful laparoscopic reoperation is limited to a few studies. METHODS: This case-control study was conducted in patients who underwent laparoscopic Heller myotomy reoperation (LHM-R) from 2008 to 2016. The operative outcomes, preoperative and last follow-up manometric parameters, and symptom questionnaire results, including the Eckardt, Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) and eating assessment tool (EAT-10) scores, were obtained. The data were compared with those of patients who underwent primary laparoscopic Heller myotomy (LHM-1). RESULTS: Thirty-five patients who underwent LHM-R and 35 patients who underwent LHM-1 were included. The reasons for failure in the LHM-R patient group included incomplete myotomy (71.4%), myotomy fibrosis (25.7%) and structural alterations in fundoplication (2.9%). The follow-up duration was 34 months for the LHM-R group and 24 months for the LHM-1 group (p = 0.557). The procedure was performed by laparoscopy in 100% of the patients in the two groups. No differences were found regarding surgical morbidity (11.4% LHM-R vs. 2.9% LHM-1, p = 0.164). The symptomatic outcomes were equivalent between groups (Eckardt p = 0.063, EAT-10 p = 0.166, GERD-HRQL p = 0.075). An IRP < 15 mmHg was achieved in 100% of the LHM-R and LHM-1 patients. At the last follow-up, 82.1% of the LHM-R patients and 91.4% of the LHM-1 patients were in symptomatic remission (p = 0.271). CONCLUSION: The results achieved with LHM-R are similar to those achieved with LHM-1. Laparoscopic reoperation should be considered an effective and safe treatment after a failed Heller myotomy.

Acute cholecystitis in neutropenic patients.

BACKGROUNDS/AIMS: The frequency of acute cholecystitis reported in neutropenic patients is between 0.4-1.65%. Clinical manifestations differ from general population as well as clinical approach, diagnosis and treatment. The aim of this work is to describe clinical characteristics, diagnostic approach, and outcomes of patients with hematological diseases that presented with neutropenia and fever associated with acute cholecystitis in a tertiary referral hospital. METHODS: We performed a retrospective analysis of patients with diagnosis of neutropenia and fever associated with acute cholecystitis in the period between January 2000 and January 2017. Quantitative variables were analyzed with mean and standard deviation, and qualitative variables with frequency and percentage. RESULTS: During the study period, 2007 patients presented with neutropenia and fever. Twelve of them (0.59%) had associated acute cholecystitis. The most common hematologic disease among these patients was lymphoblastic leukemia. Acute acalculous cholecystitis was diagnosed in 6 cases (50%). Eleven patients (91.6%) had a severe presentation and cholecystostomy was performed in 9 (75%) cases. The main cause of mortality was septic shock (33.3%). CONCLUSIONS: Treatment of acute cholecystitis in patients with neutropenia must be individualized. Cholecystostomy should be considered as a bridge therapy for an interval cholecystectomy.

Clinical characteristics and surgical treatment of schwannomas of the esophagus and stomach: A case series and systematic review.

BACKGROUND: Gastrointestinal schwannomas are slow-growing benign mesenchymal neoplasms that originate from Schwann cells of the nerve sheath of Auerbach´s plexus or less frequently from Meissner´s plexus. The main differential diagnosis of gastric schwannomas are the gastrointestinal stromal tumors (GISTs), which are classified by their immunohistochemistry. The treatment of choice for gastric schwannomas is surgery where laparoscopy plays an important role. Wedge resection, subtotal or total gastrectomy can be done. In its counterpart, esophageal schwannomas are benign tumors of the esophagus that are very uncommon since they comprise less than 2% of all esophageal tumors. The main differential diagnosis is the leiomyoma which corresponds to the most common benign esophageal tumor, followed by GIST. The treatment consists on tumoral enucleation or esophagectomy. AIM: To review the available literature about gastrointestinal schwannomas; especially lesions from de stomach and esophagus, including diagnosis, treatment, and follow up, as well as, reporting our institutional experience. METHODS: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines. The following databases were used for reviewing process: PubMed, Ovid, MEDLINE, and Scopus. Only English language manuscripts were included. All gastrointestinal schwannomas specifically located in the esophagus and stomach were included. Cases that did not report long-term follow-up were excluded. RESULTS: Gastric localization showed a higher prevalence in both, the literature review and our institution: 94.95% (n = 317) and 83% (n = 5) respectively. With a follow-up with disease-free survival greater than 36 mo in most cases: 62.01% (n = 80) vs 66.66% (n = 4). In both groups, the median size was > 4.1 cm. Surgical treatment is curative in most cases. CONCLUSION: Schwannoma must be taken into account in the differential diagnosis of gastrointestinal mesenchymal tumors. It has a good prognosis, and most are benign. A disease-free survival of more than 36 mo can be achieved by surgery.

Undifferentiated embryonal sarcoma of the liver in adult patient: A report of two cases.

Primary sarcomas of the liver are unusual neoplasms developing in adults. They constitute a heterogeneous group of neoplasms including undifferentiated embryonal sarcoma. Patients usually present with an abdominal mass and abdominal pain. Case 1: A 53-year-old woman presented with abdominal pain. Computed tomography showed an occupying mass in the right lobule and an intra-auricular multi-lobulated mass suggestive of a secondary deposit. Biopsy of the hepatic lesion revealed undifferentiated embryonal sarcoma. Despite radiotherapy and supportive measures, her overall status progressively worsened until cardiac arrest. Case 2: A 41-year-old woman presented with hepatomegaly. Abdominal imaging showed cystic lesions in the right hepatic lobule with multiple septae. The patient underwent extended right hepatectomy and a histopathological study reported high-grade undifferentiated embryonal sarcoma. Two years after surgery, a new cystic lesion in the surgical site was recorded and chemotherapy was scheduled. The lesion remained stable for three years when disease progression was observed and second-line chemotherapy was initiated. Although undifferentiated embryonal sarcoma of the liver has poor prognosis, early diagnosis is essential to increase the chances of survival. Currently, surgical resection and chemotherapy are the primary treatment modalities.

Mujer joven con hepatocarcinoma fibrolamelar metastásico; citorreducción y HIPEC: a propósito de un caso / Young woman with metastatic fibrolamellar hepatocarcinoma; cytoreductive surgery and HIPEC: a case report

Objetivo: Reportar un caso clínico de hepatocarcinoma fibrolamelar metastásico y su manejo multidisciplinario. Caso clínico: Paciente de 24 años de edad con dolor abdominal, distensión abdominal y fiebre. Se le realizó tomografía computarizada de abdomen donde se encontró tumoración hepática irregular. Se realizó laparotomía con evidencia de múltiples implantes en cavidad abdominal y se diagnosticó mediante estudio histopatológico hepatocarcinoma fibrolamelar metastásico. Se decidió realizar citorreducción más quimioterapia hipertérmica intraperitoneal (HIPEC). La sobrevida de la paciente fue de 11 meses. Discusión: El hepatocarcinoma fibrolamelar es un tumor raro. Aún no hay consenso sobre el mejor tratamiento en pacientes con metástasis que tengan buena funcionalidad. El manejo actual se basa en la quimioterapia sistémica y la resección quirúrgica en casos localizados. En el caso de nuestra paciente, la cirugía citorreductora más HIPEC se realizó con la intención de mejorar la supervivencia. Se necesita más evidencia para definir esta estrategia como tratamiento estándar.

Aim: To report a clinical case of metastatic fibrolamellar hepatocarcinoma and its multidisciplinary management. Case report: 24 year-old patient with abdominal pain, bloating and fever. A computed tomography of the abdomen was performed; an irregular hepatic tumor was found. A laparotomy was performed with evidence of multiple implants in the abdominal cavity and the histopathology report was metastatic fibrolamellar hepatocarcinoma. It was decided to perform cytoreductive surgery plus HIPEC. The patient's survival was 11 months. Discussion: Fibrolamellar hepatocarcinoma is a rare tumor. There is still no consensus on the treatment of choice in patients with metastases with good functionality status. Current management is based on systemic chemotherapy and surgical resection in localized cases. In the case of our patient, cytoreductive surgery plus HIPEC was performed with the intention of improving survival. More evidence is needed to define this strategy as standard treatment.

Morbidity and mortality following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy at a tertiary care center: initial experience.

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy increases progression-free and overall survival in patients with peritoneal carcinomatosis of appendicular or colorectal origin. The morbidity associated with this procedure is significant (30-52%). This modality is also routinely used in other peritoneal diseases with improvement of outcome. The aim of this study was to analyze the morbidity and mortality associated with this procedure. MATERIAL & METHODS: Thirteen patients had cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a period from May 2011 to March 2013 and were followed up prospectively. Demographic, pathologic, and surgical variables were recorded. The Clavien-Dindo classification was used to assess surgical complications. The main outcome variable was 30-day morbidity and mortality. Descriptive statics were used. RESULTS: The mean patient age was 52.4 ± 11.1 years. The most common diagnosis was epithelial ovarian cancer (46.2%). Most patients had an adequate preoperative functional status (77% with ECOG 0). Mean hospital stay was 13.5 ± 11.2 days and 2.7 ± 4.2 days in the intensive care unit. Major morbidity (Clavien-Dindo III or IV) observed in this series was 23%, with 0% mortality. CONCLUSION: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is a feasible option with acceptable morbidity and mortality for selected patients with peritoneal carcinomatosis in Mexico.