Favorable outcome with sentinel lymph node biopsy alone after neoadjuvant chemotherapy in clinically node positive breast cancer at diagnosis: Turkish Multicentric NEOSENTI-TURK MF-18-02-study.

PURPOSE: Factors affecting local outcome were evaluated in patients with clinically node-positive (cN+) breast cancer at diagnosis, who underwent sentinel lymph node biopsy (SLNB) alone after neoadjuvant chemotherapy (NAC). METHODS: Between 2004 and 2018, 303 cytopathology-proven cN (+) patients in a multicentric registry, who received NAC and underwent SLNB alone were analysed. All patients had regional nodal irradiation. RESULTS: Median age was 46 (23-70). Of those, 211 patients had ypN0 disease (69.6%), whereas 92 patients had ypN (+) disease including 19 (20.6%) isolated tumor cells (ITC), 33 micrometastases (35.9%) and 40 macrometastases (43.5%). At a median follow-up of 36 months (24-172), one patient (0.3%) with macrometastatic SLN was found to have locoregional recurrence as chest wall and supraclavicular LN metastases at the 60th month. Five-year disease-free survival (DFS) and disease specific survival (DSS) rates were 87% and 95%, respectively. Patients with cT3/4 (HR = 2.41, 95% CI; 1.14-5.07), non-luminal molecular pathology (HR = 2.60, 95% CI, 1.16-5.82), and non-pCR in the breast (HR = 2.11, 95% CI, 0.89-5.01) were found to have an increased HR compared to others in 5-year DFS. However, no difference could be found between ypN0 and ypN ITC and micrometastasis (HR = 1.23, 95% CI, 0.44-3.47), whereas there was a slight increase in HR of patients with ypN macrometastasis versus ypN0 (HR = 1.91, 95% CI, 0.63-5.79). CONCLUSION: ALND could be avoided in meticulously selected cN (+) patients who underwent SLNB after NAC having breast and/or nodal pCR, cT1-2, or low volume residual nodal disease with luminal pathology, as long as axillary radiotherapy is provided.

Sex- and gender-associated clinical and psychosocial characteristics of patients with psoriasis.

BACKGROUND: Sex and gender may affect disease prevalence, adverse effects and response to therapy. AIM: To analyse sex and gender differences in outpatients with psoriasis. METHODS: A cross-sectional study was conducted at IDI-IRCCS, Rome, over a 3-year period. In total, 3023 patients with psoriasis were enrolled. Anthropometric and demographic characteristics were recorded, and a dermatologist evaluated the clinical severity of disease. Quality of life (QoL) questionnaires were collected. Univariate and multivariate analyses were performed to examine factors associated with sex. RESULTS: We found sex- and gender-associated differences in clinical characteristics, disease severity, psychological distress and quality of life. Male sex was associated with body mass index, smoking, alcohol consumption, Psoriasis Area Severity Index ≥ 10 and age at onset ≥ 20 years. Female sex was associated with family history of diabetes, joint involvement, clinical type other than diffuse plaque psoriasis, higher psychological distress and a greater effect on QoL. CONCLUSION: Our study identified sex and gender differences of potential clinical relevance in psoriasis.

The Oxidative Stress-Induced miR-200c Is Upregulated in Psoriasis and Correlates with Disease Severity and Determinants of Cardiovascular Risk.

Psoriasis is a chronic inflammatory skin disease associated with reactive oxygen species (ROS) increase and a higher risk of cardiovascular (CV) events. We previously showed that the miR-200 family (miR-200s) is induced by ROS, miR-200c being the most upregulated member responsible for apoptosis, senescence, ROS increase, and nitric oxide decrease, finally causing endothelial dysfunction. Moreover, circulating miR-200c increases in familial hypercholesterolemic children and in plaques and plasma of atherosclerotic patients, two pathologies associated with increased ROS. Given miR-200s' role in endothelial dysfunction, ROS, and inflammation, we hypothesized that miR-200s were modulated in lesional skin (LS) and plasma of psoriatic patients (Pso) and that their levels correlated with some CV risk determinants at a subclinical level. All Pso had severe psoriasis, i.e., Psoriasis Area and Severity Index (PASI) > 10, and one of the following: at least two systemic psoriasis treatments, age at onset < 40 years, and disease duration > 10 years. RNA was extracted from plasma (Pso, N = 29; Ctrl, N = 29) and from nonlesional skin (NLS) and LS of 6 Pso and 6 healthy subject skin (HS) biopsies. miR-200 levels were assayed by quantitative RT-PCR. We found that all miR-200s were increased in LS vs. NLS and miR-200c was the most expressed and upregulated in LS vs. HS. In addition, circulating miR-200c and miR-200a were upregulated in Pso vs. Ctrl. Further, miR-200c positively correlated with PASI, disease duration, left ventricular (LV) mass, LV relative wall thickness (RWT), and E/e', a marker of diastolic dysfunction. Multiple regression analysis indicates a direct association between miR-200c and both RWT and LV mass. Circulating miR-200a correlated positively only with LV mass and arterial pressure augmentation index, a measure of stiffness, although the correlations were nearly significant (P = 0.06). In conclusion, miR-200c is upregulated in LS and plasma of Pso, suggesting its role in ROS increase and inflammation associated with CV risk in psoriasis.

The Italian version of the Systemic Sclerosis Questionnaire: a comparison of quality of life in patients with systemic sclerosis and with other connective tissue disorders.

AIM: Aim of the present study was to measure disability among patients with systemic sclerosis or other connective tissue disorders, using the specific Systemic Sclerosis Questionnaire (SySQ) and the Skindex-17. METHODS: Cross-sectional survey on hospitalized and day-hospital female patients in a dermatological setting, during March-May 2013. Comparison of disability and quality of life scores between patients in the two diagnostic groups. RESULTS: The use of these questionnaires in a clinical setting was well accepted. The levels of disability were slightly greater among women with systemic sclerosis in terms of general and musculoskeletal symptoms, while women with other connective tissue disorders had higher cardiopulmonary scores. The correlation between SySQ and Skindex-17 scores was low-moderate, indicating that the instruments indeed measure related but distinct constructs. CONCLUSION: The Italian version of the SySQ may provide an additional tool for dermatologists, both in the research and clinical setting. Furthermore, its use may be extended to the medical as well as to the nursing clinical practice. Results from SySQ can be very useful for dermatological nursing-care for the implementation of educational plans targeted to patients, with the objective of enabling the patients to self-manage the disability of this severe chronic condition also outside of the strictly clinical setting.

[Risk of anxiety and depression in nursing students in Rome (Italy)]. / Il rischio di ansia/depressionenegli studenti infermieri è elevato.

The aim of this study was to evaluate the risk of anxiety and depression among student nurses. If not recognized, this risk can adversely affect student health and learning and the quality of patient care. The study was performed through administration of the twelve-item General Health Questionnaire (GHQ-12) to nursing students attending two universities in Rome (Italy). Forty-seven percent of students attending University A and 38% attending University B were found to be at risk. The risk of anxiety and depression was found to be higher in females with respect to males. In both universities, a higher risk was found in those students who were dissatisfied with their academic grades (University A: p £ 0.001, University B: p = 0.03), or with their family's economic situation (A and B £ p = 0.001), and in those who reported stressful events (A: p = 0.036; B: p = 0.02). Regardless of the university, what emerges is a picture of fragile students with female students showing a greater fragility.

Sentinel Lymph Node Biopsy in Pure DCIS: Is It Necessary?

Introduction. Sentinel lymph node biopsy (SLNB) in patients with pure ductal carcinoma in situ (DCIS) has been a matter of debate due to very low rate of axillary metastases. We therefore aimed to identify factors in a single institutional series to select patients who may benefit from SLNB. Material and Methods. Patients, diagnosed with pure DCIS (n = 63) between July 2000 and March 2011, were reviewed. All the sentinel lymph nodes were examined by serial sectioning (50 µm) of the entire lymph node and H&E staining, and by cytokeratin immunostaining in suspicious cases. Results. Median age was 51 (range, 30-79). Of 63 patients, 40 cases (63.5%) with pure DCIS underwent SLN, and 2 of them had a positive SLN (5%). In both 2 cases with SLN metastases, only one sentinel lymph node was involved with tumor cells. Patients who underwent SLNB were more likely to have a tumor size >30 mm or DCIS with intermediate and high nuclear grade or a mastectomy in univariate and multivariate analyses. Conclusion. In our series, we found a slightly higher rate of SLNB positivity in patients with pure DCIS than the large series reported elsewhere. This may either be due to the meticulous examination of SLNs by serial sectioning technique or due to our patient selection criteria or both.

Factors predicting the non-sentinel lymph node involvement in breast cancer patients with sentinel lymph node metastases.

OBJECTIVE: In a significant proportion of patients, the sentinel lymph node (SLN) is the only involved axillary node. The goal of the present study was to identify predictive factors associated with a positive SLN and with a positive non-SLN in patients in whom axillary lymph node dissection (ALND) was performed. METHODS: Data was reviewed for patients with T1-2 invasive breast cancer who underwent SLN biopsy with or without axillary dissection in a single institution between July 2000 and May 2010. The SLNs were examined by serial sectioning and H&E staining, and by cytokeratin immunostaining in suspicious cases. RESULTS: Of 332 patients with SLNB, 134 had SLN positivity, and 116 of them further underwent completion axillary dissection. Patients with T2 tumors (OR=3.2; 95% CI, 1.74-5.58), or tumors with lymphovascular invasion (OR=8.0; 95% CI, 4.44-14.27), or invasive ductal cancer (OR=2.92; 95% CI, 1.1-8.0) were more likely to have a positive SLN. In patients with ALND, the non-SLN involvement rates were 10%, 11.5% and 50% in patients with isolated tumor cells (ITC), micrometastasis and macrometastasis, respectively. Finding of ITC or micrometastasis in SLNs (OR=0.28; 95% CI, 0.08-0.99) or presence of extracapsular invasion (ECI) in SLN (OR=0.24; 95% CI, 0.09-0.67) were the predictive factors of not having a non-SLN metastasis in logistic regression analysis. CONCLUSIONS: These findings suggest further axillary surgery can be best omitted in patients with micrometastasis while validation of nomograms including factors such as ECI are still needed to be studied in patients with macrometastasis.

Radio-guided occult lesion localisation for breast lesions under computer-aided MRI guidance: the first experience and initial results.

OBJECTIVE: The purpose of this study was to present an alternative technique for the pre-operative localisation of solely MRI-detected suspicious breast lesions using a computer-assisted MRI-guided radio-guided occult lesion localisation (ROLL) technique. METHODS: Between January 2009 and June 2010, 25 females with a total of 25 suspicious breast lesions that could be detected only by MRI, and for whom breast surgery was planned, underwent the computer-assisted MRI-guided ROLL technique. A seven-channel biopsy breast array coil and computerised diagnostic workstation were used for the localisation procedure. Three-phase dynamic contrast-enhanced axial images were taken. After investigating the localisation co-ordinates with the help of intervention software on a workstation, an 18 G coaxial cannula was placed in the exact position determined. Following verification of the cannula position by additional axial scans, (99m)Tc-labelled macroalbumin aggregate and MRI contrast material were injected. Post-procedure MRI scans were used to confirm the correct localisation. RESULTS: All the procedures were technically successful. The mean lesion size was 10.8 mm (range: 4-25 mm). The mean total magnet and the mean localisation times were 28.6 min (range: 18-46 min) and 13.1 min (range: 8-20 min), respectively. Grid and pillar methods were used for localisation in 24 procedures and 1 procedure, respectively. On histopathological examination, 6 malignant, 10 high-risk and 9 benign lesions were identified. All patients tolerated the procedure well. There were no major complications. CONCLUSION: This is the first report documenting the application of MRI-guided ROLL. Based on our preliminary results, this technique is very efficient and seems to be a good alternative to wire localisation.

Quality of life in patients with epidermolysis bullosa.

BACKGROUND: Epidermolysis bullosa (EB) is a rare, inherited group of disorders characterized by blistering of the skin following friction or mechanical trauma. EB has a clinical and socioeconomic impact on patients and their families. OBJECTIVES: To assess the quality of life (QoL) in patients with EB and to determine disease burden. METHODS: The study was an observational, cross-sectional postal survey. One hundred and eighty-five patients were invited to participate. Different sets of questionnaires [Short Form-36 (SF-36), Skindex-29, General Health Questionnaire-12 (GHQ-12), EuroQol 5 dimensions] were sent to patients according to age. The perceived severity of the disease was evaluated by patients or by the mothers of the younger children with EB, using the Patient Global Assessment five-point scale. Carers received the Family Strain Questionnaire. RESULTS: One hundred and twenty-five respondents were analysed. Patients with EB showed lower values in physical components of the SF-36, while the mental components were not significantly impaired. Among EB types, patients with junctional EB and severe generalized recessive dystrophic EB reported lower values and their GHQ-12 scores were significantly different from those of patients with EB simplex. There were no significant differences among EB types/subtypes for Skindex-29 values. Women had a worse QoL compared with men in all Skindex-29 and SF-36 scales (P < 0.05). GHQ-positive cases were more frequent among women (48%) compared with men (16%) (P = 0.003); GHQ-positive cases had a worse QoL compared with GHQ-negative patients. The patient QoL decreased and the family burden increased with increasing patient perceived disease severity and with increasing patient body surface involved. No differences were seen among EB types for the family burden. CONCLUSIONS: In patients with EB mental components of SF-36 scores are similar to the normal population. The perceived disease severity and skin area involved are relevant for QoL in all EB types/subtypes. EB imposes a heavy burden on the caregiver and the family. Psychological support and close monitoring of QoL may help patients with EB and their carers.

[Satisfaction and critical aspects of inpatients care among patients with psoriasis]. / Soddisfazione e criticità nella gestione del paziente ricoverato affetto da psoriasi.

OBJECTIVES: To evaluate satisfaction with care for psoriatic inpatients. Identify areas in need of interventions and actions to improve the satisfaction with care. METHODS: We analyzed 133 patients with psoriasis and 335 patients affected by other dermatological diseases in their first access at the hospital. Six determinants of satisfaction with care were investigated with a self administered questionnaire. Moreover the overall satisfaction was documented. Descriptive analysis and a multiple logistic regression analysis correcting for confounding factors were performed. Focus groups were conducted with patients to further investigate about specific aspects of relationships between patients and personnel. RESULTS: Psoriatic inpatients were less satisfied than other dermatological inpatients regarding Coordination of care, Information and education, Emotional support. Emotional support was the determinant with the smallest percentage of satisfied patients. Focus groups confirmed what was identified with the questionnaire and suggested necessary interventions. CONCLUSIONS: It is necessary to improve the communication skills of health personnel. Information for patients need to be enhanced and the management of psoriatic patients has to be improved.

Mammographic density increase in women receiving different hormone replacement regimens.

OBJECTIVE: we investigated effects of different regimens of hormone replacement therapy (HRT) on mammographic density. METHODS: ninety-five postmenopausal women, who were on different HRT regimens and completed their 4-year mammographic follow-up, were included into this retrospective and comparative study. Twenty-three of these women, who had surgical menopause, received conjugated equine estrogens (CEE) (Group I) only, 26 of them received CEE and continuous medroxyprogesterone acetate (MPA) (Group II), 21 women received CEE and cyclic MPA (Group III), and the remaining 25 women received tibolone (Group IV) therapy. Before commencing on HRT, a baseline high-resolution mammography was performed, and repeated at 6-12-month intervals during the period of 4-year follow-up. All mammographies were evaluated according to the Wolfe classification. RESULTS: a diffuse increase in mammographic density was detected in five women (22%) in group I, nine women (35%) in group II, four women (19%) in group III, and two women (8%) in group IV. The increase in mammographic density was more common among women in group II than those in the other three groups. However, a statistically significant difference was found only between groups II and IV. CONCLUSIONS: different HRT regimens have different effects on breast parenchymal density on mammography. Continuous combination HRT may be more commonly associated with an increase in breast density than other forms of HRT.

Laparoscopic approach to hepatic hydatid disease.

BACKGROUND: The aim of this paper is to present our brief experience on laparoscopic hydatid cyst surgery; we estimated the reproducibility of used techniques in conventional surgery with this relatively recent and attractive method. METHODS: Fifteen cysts in 12 selected hydatid disease patients were treated laparoscopically. Cystotomy, partial cystectomy and drainage were performed in 9 patients. Omentoplasty was added to the procedure in the remaining 3 cases. RESULTS: The mean postoperative hospital stay was 4.9 days. There was no mortality, and 1 patient developed bile leakage. Mean follow-up is 18 months. No recurrence was observed during this period. CONCLUSION: We suggest that laparoscopic treatment of hydatid disease is feasible in selected patients respecting the principles of open surgery and seems beneficial concerning postoperative comfort, hospital stay and return to daily activities.

Restorative caecogastroplasty reconstruction after pylorus-preserving near-total gastrectomy: a preliminary study.

BACKGROUND: A wide range of inevitable adverse effects may emerge after total gastrectomy, mainly due to loss of reservoir organ and exclusion of the duodenal route. None of the available reconstructive methods has achieved a satisfactory functional result. A new method has been tried to overcome postgastrectomy problems. METHODS: In this preliminary clinical study, a reconstruction technique involving interposition of the ileocaecal segment as a gastric substitute after pylorus-preserving near-total gastrectomy (restorative caecogastroplasty) was applied in six selected patients with proximal gastric carcinoma. RESULTS: Postoperative radiological and scintigraphic studies revealed adequate reservoir capacity, satisfactory neogastric emptying and a well functioning pyloric mechanism. During mean follow-up of 15 (range 3-36) months, dumping syndrome, reflux oesophagitis and weight loss were not observed. CONCLUSION: It is suggested that restorative caecogastroplasty combines the advantages of intact sphincter mechanisms and maintaining the duodenal route as well as sufficient reservoir volume. This method can be used safely as an alternative to other methods of reconstruction.

Peritoneal cytology in the determination of free tumour cells within the abdomen in colon cancer.

The presence of free tumour cells at the mesothelial surface in patients with intraperitoneal colon cancer is an important prognostic factor and may alter the decision regarding adjuvant chemotherapy. In this prospective study of 72 patients we aimed to show the existence of malignant cells in the peritoneal cavity by scraping the serosa and by peritoneal lavage. Intraoperative peritoneal cytology was performed in 72 colon cancer patients who underwent curative surgery in our department between 1992 and 1995. Specimens were obtained by peritoneal lavage and by scraping the serosa overlying the major tumour mass and an area of normal serosa at least 10 cm from the primary site. Slides were stained with haemotoxylen-eosine stain. Statistical analysis was performed with chi-squared and Fisher's exact tests. In conclusion, peritoneal washing and serosal cytological study appeared to be a simple and reliable method to detect serosal involvement and the existence of malignant cells in the peritoneal cavity.

Mammographic changes in women on hormonal replacement therapy.

OBJECTIVES: In the present retrospective study, we aimed to determine the frequency and the types of mammographic changes of breast parenchyma in women receiving hormone replacement therapy (HRT). We also investigated whether there was an association between mammographic changes and some clinical and hormonal characteristics of the women on HRT. METHODS: One-hundred and eight women were included into the study. Of the 108 women, 19 were climacteric, four premature menopause, 50 spontaneous menopause and 35 surgical menopause. Prior to the start of HRT, an initial mammography was performed and it was repeated at 6- to 18-month intervals according to the women's status. Estrogen alone was started for 35 surgical menopause women and a combination of estrogen plus progesterone for the remaining 73 women. RESULTS: Group I consisted of 96 women with no parenchymal changes or a decrease in parenchymal density on mammography, whereas group II consisted of 12 women with an increase in parenchymal density (11%) during the mean period of 24 months. Endogenous E2 levels were significantly higher in group II than in group I (52.4 +/- 42.3 pg/ml vs. 32.3 +/- 29.3 pg/ml, P < 0.05). Climacterium or types of menopause did not affect the mammographical density changes. Neither the type nor the duration of HRT had an effect on mammographic density increase. CONCLUSIONS: We concluded that the endogenous E2 level might be an important role in screening the women mammographically. Long-term follow-up studies were concluded to be needed in order to evaluate the effects of HRT on mammographic changes.

[Syndrome of solitary rectal ulcer--a rare cause of recurrent rectal hemorrhage]. / Das Syndrom des solitären Ulcus recti--eine seltene Ursache der rezidivierenden rectalen Blutung.

While the clinical symptoms and signs of SRUS are quite obvious, etiology and treatment of the disease remain to be obscure. Although the lesion is usually not solitary this name has been used for the disease. According to other authors, we also find this term inappropriate. During the last 5 years 6 cases of SRUS have been diagnosed, treated and prospectively assessed in the surgical clinic of Cerrahpasa Medical Faculty (Istanbul). Three patients were treated successfully by conservative means, transanal excision was performed and defects were sutured primarily in the other three. In one patient recurrence was seen 8 days after the transanal excision; transabdominal rectopexy was performed 6 months later. All patients have been followed up with no complaints.