Factors affecting survival in patients undergoing percutaneous transhepatic biliary drainage for malignant biliary obstruction.

OBJECTIVE: The general approach to malignant biliary obstruction (MBO) is to provide drainage in all patients with jaundice. However, the procedure is often palliative, and its contribution to survival is debated. This study aimed to investigate prognostic factors in patients undergoing percutaneous transhepatic biliary drainage (PTBD) for MBO. PATIENTS AND METHODS: All laboratory values were divided into two groups based on median values: low and high. Chi-square analysis was performed for dichotomous data. The time from the PTBD procedure to the date of death or last follow-up was considered overall survival (OS). Univariate and multivariate analyses were calculated using the Cox regression model. RESULTS: A total of 152 patients were included in the study, of whom 84 (55.3%) were male. The median OS was 71 ± 12.6 days (95% CI: 46.3-95.7). The 1, 3, 6, and 12-month OS rates were 74.3%, 45.2%, 29.2%, and 13%, respectively. In the multivariate analysis, comorbidity (p=0.029), Eastern cooperative oncology group performance status (ECOG PS) (p=0.007), pre-PTBD albumin (p=0.025), post-PTBD aspartate aminotransferase (p=0.025), chemo naive (p<0.001), and post-PTBD chemotherapy (CT) (p=0.01) were found to be independent prognostic factors. CONCLUSIONS: In patients with poor prognosis MBO, the decision for PTBD should be made multidisciplinarily, taking into consideration ECOG PS, comorbidities, albumin levels, and prior CT status.

Pertuzumab, trastuzumab and taxane-based treatment for visceral organ metastatic, trastuzumab-naïve breast cancer: real-life practice outcomes.

PURPOSE: In this study, we aimed to describe the real-life practice outcomes of pertuzumab-trastuzumab-taxane (PTT) combination in visceral organ metastatic, trastuzumab-naive breast cancer (BC) patients. METHODS: This study was conducted by Turkish Oncology Group and included 317 patients' data from 36 centers. RESULTS: Median age was 51 (22-82). Median PFS was 28.5 months, while median OS was 40.3 months. Patients with brain metastases (n: 13, 4.1%) had worse PFS (16.8 m vs. 28.5 m; p = 0.002) and OS (26.7 m vs. 40.3 m; p = 0.009). Patients older than 65 years of age (n: 42, 13.2%) had significantly lower OS results (19.8 m vs. 40.3 m; p = 0.01). Two hundred sixty-eight patients (86.7%) received docetaxel while 37 patients (11.7%) received paclitaxel. PFS and OS were similar between taxane groups. In eight patients (2.5%), 5-40% ejection fraction decrement from baseline was detected without any clinical sign of heart failure. CONCLUSIONS: Our RLP trial included only visceral metastatic, trastuzumab-naïve BC patients including cases with brain involvement who received PTT combination in the first-line treatment. Regardless of negative prognostic characteristics, our results are in parallel with pivotal trial. Further strategies for brain metastasis should be developed to improve outcomes despite encouraging results with PTT treatment. Taxane selection can be personalized and endocrine maintenance may further improve outcomes after taxanes were discontinued. To our knowledge, this is the largest scale real-life clinical practice study of pertuzumab-trastuzumab-taxane therapy to date.

Factors affecting sentinel lymph node metastasis in Turkish breast cancer patients: Predictive value of Ki-67 and the size of lymph node.

OBJECTIVES: We aimed to analyze the factors that affect the axillary lymph node involvement in Turkish breast cancer patients with clinically non-palpable axillary lymph node. BACKGROUND: Sentinel lymph node biopsy is the gold standard technique to evaluate the axillary lymph node status that directly influences the prognosis and the treatment options in breast cancer. METHODS: Breast cancer patients without axillary lymph node involvement in clinic examination were enrolled the study. Patients were categorized into the two groups according to existence of axillary lymph node metastasis or not. Demographic, histopathological and clinical data of patients were revealed retrospectively. RESULTS: One-hundred and eighty-seven patients were analyzed and 101 of patients fulfilled the criteria and were included the study. Metastatic lymph node was detected in 38 (37.6 %) patients (Group 1), and was negative in 63 (62.4 %) patients (Group 2). Sentinel lymph node metastasis were statistically significant higher in patients with Ki-67 ≥ 14 % than patients with Ki-67 < 14 % (51.9 % vs 22.4 %; p < 0.01). Likewise, the mean size of the sentinel lymph node was statistically significant higher in Group 1 compared to Group 2 (p < 0.01). CONCLUSION: Ki-67 proliferation index and sentinel lymph node size may provide a higher prediction about the sentinel lymph node involvement in patients with clinically negative axillary lymph nodes (Tab. 3, Fig. 1, Ref. 31).

Hyperbilirubinemia as a predictive factor in acute appendicitis.

PURPOSE: Our aim was to establish the role of hyperbilirubinemia as a predictive parameter for the prediction of either acute, or gangrenous/perforated appendicitis as well as to compare other parameters in a similar role. METHODS: Medical files of the patients who underwent appendectomies between September 2013 and September 2014 were evaluated. Age, gender, preoperative white blood cell count (WBC), neutrophil count (NEU), neutrophil percentage (NEU%), C-reactive protein (CRP), total/direct/indirect bilirubin levels, and the postoperative histopathological findings were recorded. The Fisher's exact, Pearson's χ (2), ANOVA, and Kruskal-Wallis tests while logistic regression for multivariate analysis was performed. p < 0.05 was accepted as statistically significant. RESULTS: The study group of 162 patients consisted of 97 (60 %) men and 65 (40 %) women with a median age of 36 (18-90). Histopathological examinations revealed normal appendix in 21 (13 %) patients, non-complicated acute appendicitis in 100 (62 %), and appendiceal gangrene/perforation in 41 (25 %) patients. WBC, NEU, NEU%, and CRP levels were significantly higher in cases of acute and gangrenous/perforated appendicitis (p < 0.01). Total and direct bilirubin levels were also significantly elevated in patients with acute and gangrenous/perforated appendicitis (p < 0.01). According to multivariate analysis, elevated CRP levels were associated with 14 times, elevated total bilirubin levels were associated with five times, and elevated direct bilirubin levels were associated with 36 times greater risk for appendiceal gangrene/perforation (p < 0.01, p < 0.05, p < 0.01, respectively). CONCLUSIONS: Hyperbilirubinemia, especially with elevated direct bilirubin levels, may be considered as an important marker for the prediction of appendiceal gangrene/perforation.

Robot-assisted laparoscopic colorectal surgery.

Colorectal cancer is one of the most common malignancies seen in developed countries. Its current treatment is based on a multidisciplinary approach entailing surgery, chemotherapy and radiotherapy. Surgery can be performed with open and minimal invasive methods. Single incision laparoscopic surgery (SILS), natural orifice transluminal endoscopic surgery (NOTES) and robot assisted laparoscopic surgery (RALS) are the final points to be reached in minimally invasive surgery. The first robotic colorectal surgical intervention was performed in 2001 after getting the FDA approval for the da Vinci surgical system in intraabdominal surgery, and since then, its use in this field gradually increased. Compared to open surgery, the advantage and superiority of robotic surgery, especially in narrow areas such as the pelvis, has been shown in many studies. It is a safe and feasible method. Although there are many existing studies about minimally invasive surgery, more randomized studies with larger case numbers should be carried out in order to establish the favorable oncological and functional outcomes of robotic surgery in addition to its obviously observed advantages.

Breast cancer in octogenarian women: clinical characteristics and outcome.

PURPOSE: Breast cancer incidence increases in the elderly but data on treatment and outcomes of elderly patients is limited. We assessed the clinicopathological features and outcomes of our patients with breast cancer aged ≥80 years in comparison with their younger postmenopausal counterparts. METHODS: The records of 83 patients diagnosed with breast cancer after the age of 80 (group 1) between 2003 and 2011 in 4 different centers were retrospectively evaluated and the clinicopathological features and outcomes were assessed in comparison with a control group (group 2) of 249 patients aged between 60-70 years. RESULTS: Median ages at diagnosis were 82 years (range 80-95) and 64 years (range 60-70) for group 1 and group 2, respectively. The incidence of invasive cancers other than ductal or lobular type was higher in group 1 than in group 2 (20 vs 8%; p=0.0177rpar;. More patients in group 1 had Charlson Comorbidty scores ≥1 than those in group 2 (49 vs 36%; p=0.011). Patients in group 1 had more conservative operations and less axillary node dissections (ALND) and they received chemotherapy, trastuzumab or radiotherapy less frequently compared to their younger counterparts in group 2. Median follow up period was 36 months (range 1-178) in group 1 and 24 months (range 12-217) in group 2. Five-year disease free survival (DFS) was 53.7 and 75.9) (p=0.005), 5-year overall survival (OS) was 61.9% and 80.47percnt; in group 1 and group 2 (p=0.001), respectively. Advanced stage (stage IV vs stage I, II, III, p=0.051) and cerbB2 positivity (p<0.001) were found to be associated with shorter DFS in patients ≥80 years of age. CONCLUSION: Although the majority of patients were undertreated in our study according to the current guidelines, mortality rates were quite low. Different biology of the disease in the elderly might explain this difference.

Evaluation of the renal function using cystatin C level in the patients receiving cisplatin-based chemotherapy.

OBJECTIVE: There are some data regarding the role of cystatin C, a cysteine proteinase inhibitor, in determining the glomerular filtration rate (GFR) more accurately. We aimed to evaluate the correlation of serum cystatin C levels with the serum creatinine levels and GFR calculated by Cockcroft-Gault and modification of diet in renal disease (MDRD) formulations in the patients who received cisplatin-based chemotherapy. We also intended to demonstrate its potential use in the early prediction of the renal function changes in these patients. MATERIALS AND METHODS: In the study, 34 patients receiving cisplatin-based chemotherapy with various malignancies were included. The levels of cisplatin were determined prior to the chemotherapy and at the end of cisplatin infusion during the therapy. GFR was calculated by Cockcroft-Gault and MDRD formulations prior to the therapy and at the end of the third course. RESULTS: A statistically significant linear correlation was found between the serum levels of cystatin C and creatinine prior to the chemotherapy (r = 0.42, p = 0.013). However, there was no correlation among the level of cystatin C subsequent to the cisplatin infusion and serum creatinine level following the third course and MDRD and creatinine clearance-Cockcroft-Gault formulations. CONCLUSION: Even though the serum cystatin C levels were correlated with the serum creatinine levels in our study, it was concluded that it was not an appropriate parameter to predict the potential impairments in the renal function during the chemotherapy.

Do different abdominal incision techniques play a role in wound complications in patients operated on for gastrointestinal malignancies ? "Scalpel vs. electrocautery".

BACKGROUND: Despite the studies of animals that demonstrate better wound healing after abdominal incisions with the use of a scalpel rather than electocautery, clinical experience does not confirm these findings. The purpose of this study was to compare the early postoperative and late-term wound complication rates between the scalpel and electrocautery in patients with gastrointestinal malignancies undergoing midline abdominal incisions. METHODS: Patients undergoing midline abdominal incisions for gastrointestinal malignancies were randomly divided into two groups according to the method used to perform the incisions: scalpel or electrocautery. Complications were investigated, diagnosed and compared in the early postoperative and late-term follow-up periods. The independent samples, chi-square, and Student's t tests were used for statistical analysis. RESULTS: Two hundred and eighteen patients were included to this study, of whom 97 (44.5%) were in the scalpel group and 121 (55.5%) in the electrocautery group. Both groups were similar with respect to their demographic, operative and postoperative characteristics. The analysis revealed no significant statistical differences in consideration of the incidences of either wound infection in the early postoperative period or incisional hernia in the late-term follow-up period between these two study groups (p > 0.05). CONCLUSIONS: Scalpel and electrocautery are similar in terms of early postoperative and late-term wound complications when used to perform midline abdominal incisions. Therefore, the choice of method remains a matter of the surgeon's preference.

A surgical approach to anogenital Buschke Loewenstein tumours (giant condyloma acuminata).

BACKGROUND: Condyloma acuminata are anogenital warts caused by human papillomavirus (HPV). Neglected giant peri-anal condyloma acuminata (Buschke Loewenstein Tumours) require major surgical procedures. This report reflects our experience concerning the aggressive surgical approach to this rarely presented type of condyloma acuminata. METHODS: The medical records of five patients, who had been surgically treated following the diagnosis of giant perianal condyloma acuminata between April, 1996 and September, 2003 were reviewed and evaluated retrospectively. Full thickness tumour and skin excisions were performed followed by delayed split thickness skin graftings in all patients. RESULTS: Five patients (3 men, 2 women) who suffered from giant condyloma acuminata lesions obliterating the anal canal were evaluated. The mean age was 36.5 years (range: 24-52). All patients underwent total surgical excisions. The wounds were left open for secondary healing, and following a mean time period of 35 days, split thickness skin graftings were performed. The histopathologic examinations of the specimens of these five patients did not reveal any malignant transformations. No recurrences were detected at the end of a mean follow-up period of 22 months and all patients were considered to be disease-free at the end of their long-term 5-year follow-up periods. CONCLUSIONS: Peri-anal condyloma acuminatum is usually a benign disease, but may grow locally to an excessive extent, developing into a Buschke Loewenstein Tumour, and may cause serious peri-anal hygiene problems. Even though the incidence of malignant transformation is rare, there is always a risk of this complication occurring. Transmission of the disease to other sexual partners is another point of concern. Therefore, this disease must be treated aggressively with total surgical excision. The results of our surgical treatment methods are satisfactory.

The ANK device: a new approach in the treatment of the fractures of the lateral malleolus associated with the rupture of the syndesmosis.

The ANK device was developed for the treatment of fractures of the lateral malleolus occurring with rupture of the syndesmosis. While it provides the anatomic reduction of the fracture and the syndesmosis, it allows the physiologic movements of the fibula. It is not used for comminuted fractures of the lateral malleolus and in cases where fibular medullary canal is narrow. We included forty-nine patients who had the ANK device applied and at least 2 years follow-up. The mean follow-up was 41 months (range 24-124). The fractures were evaluated according to the Lauge-Hansen classification; 25 cases were evaluated as supination-external rotation, 11 cases were pronation-abduction, and 13 cases were pronation-external rotation type fractures. There were also 46 fractures of the medial malleolus and three ruptures of the deltoid ligament. Twenty-nine (59,2%) patients were evaluated as excellent, 12 (24,5%) as good, 5 (10.2%) as fair and 3 (6.1%) as poor. Arthrosis was observed in 3 (6.1%) of the patients.

Medium term results of direct bronchial arterial revascularisation using IMA for single lung transplantation (SLT with direct revascularisation).

OBJECTIVE: To describe a technique of direct revascularisation of the bronchial artery using the left IMA and assess its medium term results in patients undergoing left single lung transplant (SLT). METHODS: Between March 1991 and September 1993, 22 patients who underwent direct bronchial revascularisation at the time of left SLT (20 pedicled IMA, one free IMA, and one direct anastomosis to the aorta) have been followed up for a minimum period of 1 year (mean 30 +/- 12 months). Their mean age was 47.8 +/- 9.6 and the original disease was emphysema in 19, lymphangioleiomyomatosis in two, and pulmonary fibrosis in one. The mean ischaemia time was 269.7 +/- 23.4 min. RESULTS: There was one early death (4.5%) and 3 patients were re-explored for bleeding. The actuarial survival at 1 and 3 years was 91 +/- 0.4% and 82.6 +/- 1%, respectively. Bronchial healing was excellent in all patients and angiographic studies showed patent vascular anastomosis in all 22 patients, with good run off in 20 and poor in two. One patient developed clinical obliterative bronchiolitis at 22 months (4.5%) during a period of follow up varying from 12 to 43 months (mean 30 S.D. 12). At last follow up the mean FEV1 was 1.4 +/- 0.4 and the mean FVC was 2.2 +/- 0.6. On average, each patient developed 1.5 +/- 0.6 infection episodes and 1 +/- 0.2 acute lung rejection. CONCLUSION: It is concluded that the medium term results of direct bronchial revascularisation are good. However the influence of this procedure on long term results needs further investigation.

DNA ploidy of ectopic pregnancy and first trimester spontaneous abortion investigated by flow cytometry.

BACKGROUND: To compare the success rate of DNA flow cytometry in determining the DNA ploidy status in ectopic pregnancy and first trimester spontaneous abortion. METHODS: Thirteen women with ectopic pregnancy (Group I) and 17 women with first trimester spontaneous abortion (Group II) were included into this study. DNA flow cytometric analysis was performed on all specimens. Aneuploidy was classified according to DNA index. The first trimester spontaneous abortions were also karyotyped after long-term culture of chronic villi. Student-t test and Fisher's exact test were used in statistical comparisons. RESULTS: DNA aneuploidy was found in five women with ectopic pregnancy (38.5%) versus in 12 women with first trimester spontaneous abortion (70.6%), and it was comparable. A triploidy and a tetraploidy were detected in group I. Six tubal ectopic pregnancies were unruptured at laparatomy and four of them had aneuploid DNA content. CONCLUSIONS: We believed that DNA flow cytometry was successful in determining the ploidy status of ectopic pregnancy and first trimester spontaneous abortion. In addition, it was interesting that ectopic pregnancies with aneuploid DNA content tended to be unruptured. However, this suggestion needs to be confirmed by further studies with larger numbers of cases.