The effect of immunonutrition on tumor infiltrative t lymphocytes and regulatory t cells in rectal tumor patients receiving neoadjuvant chemoradiotherapy: a prospective randomized clinical study.

BACKGROUND: The rationale behind using immunonutrition in cancer patients is to prevent malnutrition, manage the host's immune response, and keep cancer under control by utilizing the potential immune system available in the host against the tumor. This prospective- study aims to assess the impact of immunonutrition on tumor-infiltrating lymphocytes (TILs) and regulatory T cells (Tregs) in rectal cancer patients receiving neoadjuvant chemoradiotherapy. METHODS: This is a single-center, prospective study. Forty patients diagnosed with middle and lower rectal tumors were enrolled in the study between March 2018 and December 2019. Nutrition protocols were given to all study subjects prior to surgery. Tissue CD4, CD8, and Fox P3 expression prior to enrollment (endoscopic biopsy specimens) and following surgery (resected tissue) were compared. RESULTS: Longitudinal data was available for 30 patients. In the present study, 15 patients were given immuno-nutrition, and 15 patients received standard nutrition. The immunonutrition and standard nutrition groups were similar regarding CD4 [10 (5-20) vs. 10 (10-10), p = 0.653], CD8 [30 (20-35) vs. 30 (20-40), p = 0.870], lymphocyte counts [2 (2-3) vs. 2 (2-3), p = 0.325], fox p3 value [10 (10-10) vs. 10 (10-10), p = 0.775], and CD4/CD8 ratio [0.33 (0.29-0.66) vs. 0.50 (0.29-0.50), p = 0.870] on endoscopic biopsy. CD4 [10 (7.5-25) vs. 30 (10-50), p = 0.050], CD8 [60 (40-60) vs. 50 (40-60), p = 0.713] and Fox P3 [10 (5-10) vs. 10 (2.5-10), p = 0.935] were also similar in tissues extracted by surgery. However, the standard nutrition group had significantly higher CD4/CD8 values in their tissues removed on surgery [0.25 (0.14-0.50) vs. 0.66 (0.28-1), p = 0.026]. DISCUSSION: The present study revealed that CD4/CD8 ratios were lower in the immunonutrition group in comparison to the group receiving standard nutritional supplements before surgery.

Use of the Systemic Immune Inflammation Index, TNM classification, and CEA in pre- and post- prognostic evaluation of sporadic colorectal cancer.

AIM: The aim of this study was to investigate the correlation between preoperative systemic immune inflammatory index (SII) and carcinoembryonic antigen (CEA) and postoperative lympho-vascular invasion and TNM stage in patients with colorectal carcinoma. MATERIAL AND METHODS: A total of 153 patients with colorectal cancer admitted to our tertiary hospital between 2014 and 2018 were included in the study. RESULTS: While 71.2% of the patients had low preoperative CEA values, 28.8% had high preoperative CEA values. Lymphovascular invasion rate was found to be significantly higher in patients with high CEA levels than those in low levels (70.4% vs. 39.4%, p=0.002). The percentage of patients with lymphovascular invasion with a high SII (60.0%) was significantly higher than those without lymphovascular invasion (p=0.015). CONCLUSION: In our study, serum CEA and SII index values were found to provide critical information in terms of showing lympho-vascular invasion, which is considered as an independent "bad" prognostic factor in patients with colorectal carcinoma. In conclusion, we consider that CEA and SII index values can be used to determine the prognosis of patients with colorectal cancer. KEY WORDS: Carcinoembryonic antigen, Colorectal carcinoma, Microsatellite, lymphovascular invasion, TNM.

Incidental gallbladder cancer: a retrospective clinical study of 40 cases.

Purpose: Cholecystectomy is one of the most common surgeries today due to gallbladder diseases. The most prevalent malignancy of the biliary tract is gallbladder cancer. We aimed to discuss the results of our patients who underwent cholecystectomy for benign reasons in our clinic and who had gallbladder cancer due to pathology. Methods: The results of cholecystectomy performed in General Surgery Clinic of Seyhan Government Hospital were evaluated. Cases diagnosed as gallbladder as a result of histopathological examination were included. Preoperative ultrasonography, laboratory findings, and postoperative pathology results of the patients were reviewed retrospectively. The pathologist repeated histopathological evaluations. Results: Between 2010 and 2019, incidental gallbladder cancer (IGBC) was detected in 40 patients (0.3%) in 11,680 cholecystectomy operations. Of the patients diagnosed with IGBC, 14 (35.0%) were T1a, 11 (27.5%) were T1b, 11 (27.5%) were T2, and 4 (10.0%) were T3. T4 tumor was not seen in any patient. Three patients who were T1b at initial evaluation were identified as T2 at evaluation for the study. The pathology results of 37 patients (92.5%) were adenocarcinoma, 2 (5.0%) were adenosquamous type, and 1 (0.5%) was squamous cell carcinoma. Conclusion: There has been a remarkable increase in the number of IGBCs over the past 20 years. Appropriate staging and histopathological evaluation are essential in guiding the surgeon's operation. It is crucial to accurately determine the T stage, the most influential parameter on patient survival and residual recurrences. The distinction between pathologic (p) T1a and pT1b should be made carefully. Surgery is the only potentially curative method.

Modified techniques versus Hadfield's procedure in patients with periductal mastitis.

BACKGROUND: Periductal mastitis (PM) is a rare disease characterized by chronic inflammation of the terminal mammary ducts. Complete removal of terminal lactiferous ducts with Hadfield procedure is a previously defined technique in treatment but carries various complications risks. This study aims to evaluate the effectiveness of modified techniques in the treatment of PM. METHODS: Twenty women who underwent surgery due to PM between January 2012 and December 2019 were retrospectively analyzed. Types of PM were determined. All patients were operated on with three different incisions [Hadfield's operation with periareolar incision (n:11), periareolar combined radial incision (n:7), and round block incision (n:2)]. RESULTS: The mean age was 37.5 ± 6.5 years (range: 24-49). Sixty percent of patients had type 3 PM. In Hadfield's procedure, NAC retraction (n:2), seroma (n:1), and hematoma (n:1) were seen. In the periareolar incision combined radial incision group only one patient had complications (seroma) and none in the round block method. Follow-up was 12 ± 1.5 months and disease relapse occurred in two patients in the Hadfield group. Patients who underwent round block were more satisfied with the appearance of the nipple. CONCLUSIONS: In the treatment of PM, the main principle of surgical treatment is the excision of the affected canal with a clear margin. Apart from the classical Hadfield procedure, the round block method and periareolar combined radial incision techniques can be performed in the treatment of PM.

Gastrointestinal Stromal Tumours.

OBJECTIVE: To analyse the gastrointestinal stromal tumours (GIST) patients' inter-demographics, histological type and association with secondary tumours. STUDY DESIGN: A case series. Place and Duration of the Study: Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey, between January 2010 and December 2018. METHODOLOGY: Fifty-eight patients diagnosed with GIST and operated at the study place were analysed retrospectively. The demographics, symptoms, diagnosis, treatment, tumour location, histopathology, risk classification, and prognosis were recorded. RESULTS: The mean age was 60.62 ± 10.63 (37-83) years and the male to female ratio was 1:1. The most common symptom was abdominal pain (51.7%). Tumour site was the stomach in the majority (86.2%), followed by the small intestine and colon. One patient also had a secondary malignancy. The most common histologic type was spindle cell, followed by mixed cell type. C-kit (CD117) and CD34 mutations were positive in 87.9% and 75.9% of the cases. One patient had liver metastasis on diagnosis and another had peritoneal implants per-operatively, who died after 36 months due to midgut volvulus. The mean follow-up period was 32.03 ± 13.67 months. Two patients developed liver metastasis in the early postoperative period. CONCLUSION: Surgical resection and imatinib treatment have been provided with good prognosis. The most common histology is spindle cell type. GISTs might be associated with other cancers which should be searched and analysed. Key Words: Gastrointestinal stromal tumour, Secondary malignancy, Treatment, Prognosis.

The effect of transverse fascia inversion on postoperative seroma in direct hernias treated with laparoscopic TAPP procedure.

AIM: This study aims to reveal the results of the transverse fascia inversion technique applied in laparoscopic transabdominal preperitoneal (TAPP) procedure to reduce the risk of seroma in direct hernias. MARIAL AND METHODS: Patients who underwent elective inguinal hernia repair with the laparoscopic TAPP procedure were retrospectively evaluated. Indirect inguinal or femoral hernias and emergency operations were excluded, and only patients with direct or indirect + direct inguinal hernia were included in the study. The patients were divided into two groups as those with and without transverse fascia inverted. Operative and postoperative clinical features were compared. RESULTS: Sixty-two patients with 75 inguinal hernias were included in our study. Six of the patients were women. Thirty-one patients had a right inguinal hernia, 18 patients had left, and 13 patients had a bilateral inguinal hernia. The operation time was longer in the inversion group, but this was not statistically significant. One-day postoperative pain and postoperative hospital stay were similar in the two groups. In the inversion group, the peritoneal breach occurred in 4 patients, and gonadal vessel injury occurred in 1 patient (p = 0.435, p = 0,376, respectively). When postoperative complications are examined, there was no statistical difference between subcutaneous emphysema, urinary retention, and hematoma development (p>0.005); however, seroma formation was lower in the inversion group (p = 0.031). CONCLUSION: Inversion and fixing the direct hernia pouch to the cooper ligament reduces the risk of seroma formation in the laparoscopic TAPP procedure. KEY WORDS: Direct hernia, Laparoscopy, Seroma, Transabdominal preperitoneal procedure.

Gastric medullary carcinoma. A case report and review of the literature.

Medullary gastric carcinoma (MGC) is a rare gastric neoplasm characterized by histological appearance of dense lymphocytic infiltration of the stroma. The prevalence of MGC among all gastric neoplasms is about 1%. Although it is classified within the poorly differentiated carcinomas, the biological activity of MGC is similar to that of the well differentiated carcinomas. Hereby, we present a case of a 64-year-old male patient who underwent upper gastrointestinal (GI) endoscopy for abdominal pain over the last 2 months. The pathological findings of the GI endoscopy specimen revealed adenocarcinoma of the stomach. Subsequently, the patient underwent total gastrectomy and D2 lymph node dissection. Pathological evaluation of the excised specimens samples were compatible with MGC (gastric carcinoma with lymphoid stroma) which was staged as T2N0M0. This paper purposed to describe the clinical and pathological findings of MGC. KEY WORDS: Gastrectomy, Gastric carcinoma, Medullary.

Xanthogranulomatous cholecystitis: a rare gallbladder pathology from a single-center perspective.

PURPOSE: The aim of this study was to review patients with xanthogranulomatous cholecystitis (XGC). METHODS: A total of 79 patients diagnosed with XGC were included in the study. The criteria for XGC in the pathology specimens were the presence of histiocytes, cholesterol deposits, lipids, and focal or widespread wall enlargement. RESULTS: Patients were diagnosed with XGC, of which 52 (65.8%) were male and 27 (34.2%) were female, creating a male-to-female ratio of 2:1. The mean age was 65.8 ± 14.3 years (range, 36-97 years). The most common presenting symptom was abdominal pain (63.3%), and the least common presenting symptom was jaundice (8.9%). Of the total, 25 patients were found to have pathological conditions with the potential to obstruct the bile duct or to slow bile flow. A frozen section examination was performed on 20 patients due to suspicion of a tumor by intraoperative macroscopic examination. However, no malignancy was detected in the cases who underwent a frozen section examination. An increase in wall thickness of the gallbladder was observed in 81.6% (n = 31) of the patients on computed tomography scans and in 81.8% (n = 18) of the patients on magnetic resonance imaging scans in which possible tumor lesions were reported, but no tumor was detected. CONCLUSION: It is difficult to diagnose XGC either preoperatively or intraoperatively, and further imaging methods are needed in the preoperative period other than ultrasonography. However, a definitive diagnosis depends exclusively on pathologic examination.

Bilateral breast lesions mimicking metastases of hepatocellular carcinoma in a male patient.

Hepatocellular carcinoma metastases to the breast have been reported only rarely. A 63-year-old male patient with metastatic hepatocellular carcinoma presented with a lump in his left breast. On physical examination, there was a hard, well-circumscribed, and partially mobile mass of 2 cm in diameter in the lower middle quadrant of the left breast. Breast ultrasound revealed a hypoechoic solid lesion of 1.8 cm × 1.9 cm in diameter in the lower middle quadrant of the left breast. F-18 FDG PET/CT imaging revealed bilateral subcutaneous nodular lesions of anterior chest wall that were adjacent but not invasive to the glandular tissues of the breasts, with high SUVmax values. Tru-cut biopsy result of the mass in the left breast region was reported as hepatocellular carcinoma metastasis. Positive immunohistochemical staining for Hep Par 1 and glypican-3 were detected. While the patient was on sorafenib therapy, he died 6 months later. Hepatocellular carcinoma is a common malignancy for which chronic hepatitis B infection has been defined as the most common etiologic factor. The most frequent metastatic sites are the lung, bone, lymphatics, and brain, respectively, and metastases to the breast have been reported extremely rarely. Breast metastasis from non-mammary malignant neoplasm is rare, accounting for approximately 2% of breast tumors. Metastasis to the breast from an extramam mary neoplasm usually indicates disseminated metastatic disease and a poor prognosis. It should be borne in mind that a mass lesion detected in the breast region by physical examination and imaging methods may be a hepatocellular carcinoma metastasis in male or female patients with hepatocellular carcinoma. KEY WORDS: Breast, Hepatocellular carcinoma, Metastasis.