Robotic-Assisted Pelvic Surgery: Early Outcomes in a Single Institution.

Introduction: This article reports the authors' experience with their first 50 consecutive robotic pelvic procedures, aiming to determine the feasibility and safety of adopting robotic pelvic surgery. Robotic surgery offers several benefits for minimally invasive surgery, but its applicability is hindered by cost and limited regional experience. This study aimed to evaluate the feasibility and safety of robotic pelvic surgery. Material and Methods: This is a retrospective review of our initial experience with robotic surgery for colorectal, prostate, and gynaecologic neoplasia, between June and December 2022. The surgical outcomes were evaluated in terms of perioperative data, such as operative time, estimated blood loss, and length of hospital stay. Intraoperative complications were recorded, and postoperative complications were evaluated at 30 days and 60 days after surgery. The feasibility of the roboticassisted surgery was assessed by measuring the conversion rate to laparotomy. The safety of the surgery was evaluated by recording the incidence of intraoperative and postoperative complications. Results: Fifty robotic surgeries were performed over 6 months, including 21 interventions for digestive neoplasia, 14 gynaecologic cases, and 15 prostatic cancers. Operative time ranged from 90 to 420 minutes, with two minor complications and two grade II Clavien-Dindo complications. One patient required prolonged hospitalization and an end-colostomy, deriving from an anastomotic leakage requiring reintervention. No thirty-day mortality or readmissions were reported. Conclusion: The study found that robotic-assisted pelvic surgery is safe and has a low rate of transfer to open surgery, making it a suitable addition to conventional laparoscopy.

Evaluation of circulating tumor cells in colorectal cancer using flow cytometry.

OBJECTIVE: We aimed to evaluate the prognostic value of circulating tumor cells (CTCs) and the impact of intraoperative tumor manipulation on CTCs in colorectal cancer (CRC) patients. METHODS: We performed a prospective study on 40 patients with CRC stages I to IV who received curative surgery using the no-touch technique. Flow cytometry was used to identify CTCs in peripheral blood samples (4 mL/sample) collected at two surgical moments: skin incision (T1) and after surgical resection (T2). A threshold of ≥4 CTCs/4 mL blood was established for considering patients CTC positive. RESULTS: In the univariate analysis, CTC evaluation at T2 was correlated with female sex, vascular invasion, tumor localization in the colon and metastatic lymph nodes. In the multivariate analysis, only female sex and colon cancer maintained statistical significance. At a medium follow-up of 15 months (1-25 months), the mortality rate was 10% (n = 4), with no significant differences between the overall survival of T1 or T2 CTC-positive and CTC-negative patients. CONCLUSIONS: Flow cytometry is a feasible CTC identification technique in CRC, and although surgical manipulation has no influence on CTC numbers, CTCs may serve as a prognostic and predictive factor.

"Liquid Biopsy" - Is it a Feasible Option in Colorectal Cancer?

It is important for surgeons to keep up with improvements both in and outside their field. As medicine evolves, new techniques appear, and oncology is one of the main beneficiaries. "Liquid biopsy" is one of the most recent domains of interest in oncology, as it may provide important details regarding the characteristics of the main tumor and its metastases. Malignant cells are in a continuous dynamic, which makes the initial diagnostic biopsy and the pathological specimen evaluation insufficient in the late evolution of the disease, when relapse or metastases may appear. The fact that the healthcare provider is able to find out additional information about the tumor at a given time, by evaluating a blood sample to obtain a "liquid biopsy" is of utmost importance and gives multiple potentially usable data. There are three means of obtaining biological material that may be used as "liquid biopsy": evaluation of circulating tumor cells, circulating tumor DNA and exosomes. The most intensely studied entity is that of circulating tumor cells, with different applications, amongst which the most important, at present time, is the prognostic value that has important demonstrated implications, not only in breast and prostate cancer, but also in colorectal cancer. Although surgery will, most certainly, not be replaced by other treatments when aiming for a curative approach to rectal cancer, it is important for the surgeon to know information about complementary fields, one of which is comprised by "liquid biopsy".

The Influence of Neoadjuvant Treatment on the Number of Lymph Nodes on the Surgical Specimen in Mid and Low Rectal Cancer - A Retrospective Single-Centre Study.

Introduction: In this study, we aim to identify the impact of neoadjuvant radiation treatment upon the number of harvested and positive lymph nodes in the surgical specimen; in addition, we tried to identify the impact of chemotherapy in association with radiotherapy on said structures. Patients and methods: In the study we included patients treated for rectal cancer within a single oncologic surgical Unit serving the north-eastern part of Romania, over a period of 5 and a half years, between May 2013 and April 2018. Firstly, we compared pathologic lymph node status to pretherapeutic staging. Secondly, we compared lymph node values in relation to the treatment scheme. Results: There was a total of 498 patients treated radically through open surgery for low and mid rectal cancer. We saw a decrease in N staging in 218 cases, 65 remaining stationary and 10 increasing their lymph node staging on the surgical specimen. We identified significant differences between the total number of lymph nodes (17.4 vs 24.2, p 0.001), the number of positive lymph nodes (1.4 vs 3.4, p 0.001) and the ratio between positive and total lymph nodes (0.08 vs 0.14, p 0.001) in patients with and without neoadjuvant treatment respectively. However, there was no statistical difference between patients with and without chemotherapy associated to radiotherapy in the neoadjuvant treatment plan (p=0.539, p=0.58, p=0.575). Conclusion: This study shows there are significant variations according to the application of neoadjuvant treatment, between the numbers of positive and total lymph nodes, as well as the positive/total lymph node ratio.

Hindgut and Midgut Neuroendocrine Tumors - Therapeutic Approach.

Introduction: Neuroendocrine tumors of the gastro-entero-pancreatic system have a variety of components, clinical manifestations and prognostic indices according to their anatomical site. Therefore, their diagnostic and management strategies differ a great deal. Prognosis concerning NETs can be poor due to the degree of differentiation, early metastasizing and the high degree of invasiveness. Material and Methods: For the present study, the patient files were evaluated and the parameters of interest were followed. Results: Over the course of 6 years there were 37 patients diagnosed with and treated for NETs, regardless of primary tumor site. There were 9 patients with NETs of the primite mid- and hindgut thusly: 5 cases with colorectal NETs and 4 cases of small bowel NETs. 6 patients benefited from radical surgical treatment, 2 cases with palliative procedures and only one patient with tumor biopsy. The tumors were evaluated according to the 2010 WHO classification based on the number of mitoses and the Ki67 proliferation index. Adjuvant treatment was adapted according to staging and histopathological parameters. Conclusions: Despite recent progress in managing NETs, there are still many controversial aspects regarding the management of these cases, mainly about timing the right sequence of therapy.

Pelvic exenteration, a surgical treatment option for locally advanced, primary and recurrent neoplasia.

Pelvic exenteration (PE) is an extensive surgical procedure for locally advanced primary neoplasia (LAPN) or recurrent neoplasia (RN) that consists in the en bloc removal of the pelvic organs (rectum, internal genital organs and bladder) associated with pelvic lymph nodes. PE is classified into anterior, posterior and total, supra or infralevatorian approaches. Our aim was to evaluate the surgical procedure and the resection margins in correlation with postoperative complications and morbidity rates after PE in patients treated in a single surgical unit. The study group comprised patients diagnosed with different malignancies, surgically treated by using PE procedure, during 2012-2018. The cohort included 121 cases with LAPN (n=98, 80.99%) and RN (n=23, 19%), mostly female (n=114, 94.21%), with a mean age of 61.16 (33-85) years. LAPN had predominantly digestive (n=48, 49.98%) and gynecological (n=28, 28.57%) origins, while the majority of RN cases were cervical cancers (n=9, 39.13%). The univariate analysis showed that the gynecological origin of the tumor (p=0.02), urinary stoma (p=0.02) and posterior PE (PPE) (p=0.004) were significant prognostic factors for postoperative complications. After performing the multivariate analysis, only the gynecological origin (p=0.02) of the tumor and PPE (p=0.03) remained determining factors for postoperative complications. PE is a disabling surgical procedure associated with high postoperative mortality and morbidity, although it is often the only solution for advanced cases. The judicious selection of patients who can benefit from such extensive surgery is compulsory. Our study suggests that the gynecological origin of the tumor and PPE are key factors in postoperative complications.

Clinical Value of Hematological Biomarkers in Uterine Cervical Cancer.

Certain combinations of the hematological components, specifically, neutrophils and lymphocytes, named neutrophil to lymphocyte ratio (NLR) or multiplication of neutrophil and monocyte (MNM) have been shown to have prognostic value in a variety of cancers. MATERIAL AND METHODS: Retrospective study which included 133 patients with uterine cervical cancer with or without neoadjuvant therapy based on prognostic factors and correlations between NLR and MNM values, markers that were analyzed as continuous variables. This study aimed to establish the critical value of hematological markers. Results: NLR is significantly lower for preoperative stages I and II (p = 0.0004). There is a significant association between NLR and lymph node metastasis (p = 0.016), parametrial invasion (p = 0.035), lymphovascular space invasion (p = 0.0151) and tumor size (p = 0.0017). Correlational analysis showed that there is a significant association between MNM and lymph node metastasis (p = 0.020), parametrial invasion (p = 0.00010), lymphovascular space invasion materially affecting the value MNM (p = 0.0018), tumor size more than 4 cm (p = 0.0314). NLR and MNM were significantly lower in patients with complete response to neoadjuvant treatment. Discussion: The results of this study outlines the importance of hematological panel and parameters that can be easily used at no extra cost to establish further evolution of patients to treatment.

Colon cancer at the molecular level--usefulness of epithelial-mesenchymal transition analysis.

Colorectal cancer (CRC) is the third form of cancer in both men and women. In Romania, the incidence of CRC in 2000 is 17.74 %ooo, in 2002 becoming the second cause of death. We reviewed a series of studies that are related to colon cancer and studied the epithelial-mesenchymal transition at the front of tumor invasion (EMT). Cellular phenotypic changes characteristic of EMT can be induced by the absence of transition cofactor (p300) involved in cellular regulation. Loss of syndecan-l marker is associated with local tumor stage and metastasis. Modulators of protein kinase resistance was associated with changes in genes involved in EMT (including vimentin hyperexpression) and genes involved in invasion (N-cadherin) with a decrease expression of genes involved in epithelial cell adhesion (E-cadherin). Progression in colon cancer is characterized by activating mutations in Ras genes and tumor growth factor action. Vimentin expression associated with EMT initiates molecular program. One of the characteristics of EMT is the loss of E-cadherin. TGF-p (transforming growth factor beta) induces epithelial-mesenchymal transition in colon cancer cell lines with the microsatellite stability, inducing cell invasion and migration. EMT is a critical early event involved in invasion and metastasis of colorectal cancer, characterized by the presence of markers specific to each phenotype, epithelial or mesenchymal. Multiple biomarkers involved in the induction of EMT may represent future therapeutic target in the treatment of colonic neoplasia.

Expression of bmi-1 protein in cervical, breast and ovarian cancer.

UNLABELLED: B-cell-specific Moloney murine leukemia virus integration site 1 (Bmi-l) is a member of polycomb group, which participates in axial patterning, hematopoiesis, cell cycle regulation, and senescence. Overexpression of Bmi-1 has been reported in various human cancers and proved to be associated with poor survival. DISSUCION: Bmi-I is expressed by various tumors and therefore may contribute to malignant transformation. Bmi-I not only can lead mammary epithelial cells to senescence and immortalization, but also plays a key role in breast cancer. A significant correlation was observed between Bmi-1 expression and axillary lymph node metastases in lymph-ductal breast cancer. Bmi-1 is expressed in cervical cancer and correlated with a poorer prognosis, suggesting that this protein participates in the development and progress of cervical cancer. Regarding ovarian cancer, the results of several immunohistochemical studies revealed overexpression of Bmi-1, especially in poorly differentiated ovarian carcinoma. There is a strong correlation between histological grade, clinical stage and its expression. CONCLUSIONS: Human genes of polycomb group correlated with various hematological and epithelial cancers identify new mechanisms of malignant transformation and pave the way for developing new cancer treatments and identify new diagnostic markers. Bmi-1 and its expression in tissues taken from patients with cervical, breast and ovarian cancer could be a marker for diagnosis and prognosis, and not least a potential target of antitumor therapy.