Extent of surgical procedure in triple negative breast carcinomas.

INTRODUCTION: Triple negative breast carcinomas (TNBC) account for approximately 15-20% of all breast carcinomas. This subtype is characterised by an unfavourable prognosis with early locoregional recurrence a metastases. Only few studies have focused on the impact of local surgery on the overall therapeutic outcome. However, decisions are difficult to make in the case of TNBC, and no particular molecular subtype or marker exists that would make the decision-making process easier. The aim of our retrospective study was to analyse the TNBC surgical management outcomes at EUC Clinic in Zlin. METHODS: 440 women with breast carcinoma were operated on at EUC Clinic from 2014 to 2016, including 29 patients with TNBC; bilateral carcinoma was present in one case. Neoadjuvant chemotherapy (NAC) was indicated in 6 cases. The tumour centre was marked with a clip. The extent of surgery depended on the residual size of the tumour. Sentinel lymph node biopsy was indicated in clinically negative lymph nodes; further management followed the Z0011 study if the biopsy was positive. Axillary lymph node dissection was performed after NAC. In all cases, surgery was followed by systemic chemotherapy, and by radiotherapy in the case of breast-conserving procedures. RESULTS: The group included 29 women and one patient with bilateral carcinoma, i.e. 30 cases of TNBC. Mean age was 57 years and median age was 55.5 years. Mean follow-up was 62.9 months, with the median of 69.9 month. NAC was indicated in 6 patients; complete pathological response was achieved in one case. NAC was followed by mastectomy in 5 cases including a bilateral procedure in one case, and by breast-conserving surgery in one case. Axillary dissection was performed in all cases. Breast-conserving surgery and sentinel node biopsy predominated in the group (16 cases). Local recurrence was observed in 4 cases, 2 times as an isolated local recurrence after one year and 2 times as part of generalization, always after mastectomy. Six patients died of generalized disease. No regional recurrence was observed. CONCLUSION: TNBC is characterised by a worse prognosis and a higher rate of local recurrence. As confirmed by our study, the results of breast-conserving surgery can be comparable to those of radical procedures, and thus radical surgery should be indicated prudently.

Ductal carcinoma in situ and the extent of surgery.

INTRODUCTION: Ductal carcinoma in situ (DCIS) is a very heterogenous disease. The incidence of DCIS has been increasing with the adoption of mammography screening. This opened new questions concerning surgical and adjuvant therapy.  Methods: We retrospectively observed the incidence of DCIS amongst the patients that underwent surgical resection in EUC clinic Zlín between 2017 and 2019. We also assessed the extent of breast surgery including interventions in axilla and the adjuvant therapy.  Results: There were 616 breast cancer patients, of whom 44 (7.1%) were diagnosed with DCIS. Breast-conserving surgery was performed in 35 (80%) patients. Lumpectomy alone was performed in 21 (47%) patients. Mastectomy was indicated primarily in 9 cases with additional two mastectomies performed to achieve clear margins. All sentinel nodes were negative.  Conclusion: Results confirmed, that the surgical therapy as well as radiotherapy and hormonal treatment are performed according to guidelines at our department. Proportion of sentinel node biopsy is remarkably higher, therefore an improvement in this area is our next goal.

Targeted axillary dissection with preoperative tattooing of biopsied positive axillary lymph nodes in breast cancer.

Sentinel lymph node biopsy (SLNB) has emerged as an alternative to axillary lymph node dissection during breast cancer surgery during the last 2 decades. However, there are several controversies regarding the indication of the sentinel node biopsy after neoadjuvant chemotherapy which can convert positive lymph nodes to negative. The false-negative rate after neoadjuvant chemotherapy is unacceptably high. This high false-negative rate can be decreased by marking of the positive lymph nodes and removal during sentinel lymph node biopsy procedure in addition to the sentinel lymph nodes. The aim of this study was to investigate the possibility of carbon tattooing of the positive sentinel lymph nodes before neoadjuvant chemotherapy. In 2016, a prospective protocol was launched investigating the black carbon tattooing procedure of the suspective and positive axillary lymph nodes by injecting 0.1-0.5 carbon ink in normal saline under ultrasound guidance. All patients underwent black carbon tattooing of the suspected or positive axillary lymph nodes before the chemotherapy or one week before the primary surgery when chemotherapy was not indicated in the neoadjuvant setting. Sentinel lymph nodes together with lymph nodes marked by the black carbon ink were removed and histologically evaluated. So far 27 patients were treated under this protocol. Breast saving surgery was performed in 22 cases and mastectomy in 5 cases. All patients had invasive ductal carcinoma. In 20 patients neoadjuvant chemotherapy was indicated and in 7 patients primary surgery was performed. All lymph nodes marked by black carbon ink were successfully identified and removed. Sentinel lymph node biopsy was performed in 8 cases and sentinel lymph node biopsy followed by axillary dissection in 15 cases. Axillary dissection alone was performed in 4 cases. In 19 cases, the black carbon ink was present in the sentinel lymph node at the same time and in 4 cases carbon dye was present in other lymph nodes than the lymph node identified during SLNB, which corresponds to 17.4%. In the group of patients undergoing primary surgery, in one case from six, the sentinel lymph node was negative and the lymph node marked with carbon ink positive which represents false-negative lymph node and failure of the SLNB procedure. After neoadjuvant chemotherapy, there was no false-negative lymph node identified, but the conversion of the positive lymph nodes to negative was present in 10 cases (50%). There were no complications attributed to carbon ink tattooing. The results of positive sentinel lymph nodes tattooing have confirmed that this method is safe and allows a decrease in the false negativity rate during the sentinel node biopsy procedure.

Surgical treatment of breast carcinoma after neoadjuvant therapy.

INTRODUCTION: Neoadjuvant therapy (NT) applied before breast cancer surgery can lead in favourable cases to regression of the tumor or its total disappearance - pathological complete response (pCR). Due to downstaging after NT, the extent of the surgery can be reduced. pCR represents an important prognostic factor for survival. The aim of this study was to evaluate the effectiveness of NT resulting in pCR on our sample of patients and to assess the frequency of locoregional recurrence (LRR) depending on the extent of the surgery in postoperative care. METHODS: This retrospective study was performed on a sample of 96 patients who underwent breast cancer surgery between 2006 and 2018 after previous NT. On the basis of the histological examination after surgery we evaluated the degree of regression and thus also pCR. In postoperative care we followed the patients for any occurrence of LRR in the breast and axilla. RESULTS: pCR (Chevallier 1) was observed in 26 cases - 27.1%. During follow-up in postoperative care, 8 cases of LRR occurred - 8.3% (5.2% after mastectomy and 2.1% after breast-conserving surgery). Mean follow-up was almost 30 months with the median of 26.5 months. CONCLUSION: With the development of new NT procedures a significant rise in pCR has occurred, predominantly in HER 2+ and triple negative subtypes, thus leading to a decreased incidence of LRR. The number of breast-conserving surgeries with sentinel lymph node biopsy is rising. In a select group of patients breast-conserving surgery is safe and is associated with a low number of LRR events.

Papillary thyroid microcarcinoma and papillary thyreoid cancer at the Department of Surgery, EUC Clinic Zlín.

INTRODUCTION: Papillary thyroid cancer (PTC), especially micropapillary variant (MPTC), is the most common thyroid malignancy. Biological behavior is not aggressive and the patients prognosis is satisfactory. The objective of our comparative retrospective study was to evaluate whether the incidence is rising in the Region of Zlín and if less extensive approach was adopted by Czech endocrinologists. METHODS: We compared 2 groups from years 2005-2008 and 2014-2018. The incidence of thyroid cancer, the PTC and the MPTC, the extent of the surgery and the lymphadenectomy, number of removed lymph nodes and the number of positive lymph nodes were observed. RESULTS: We gathered 1353 patients in group 1. We found 220 malignancies (16.3%), 180 (81.8%) were PTC with MPTC variant in 44.4% (80 patients). All patients underwent a total thyroidectomy. We made 18 central and 10 lateral lymphadenectomies, 280 lymph nodes were collected with meta-stasis in 29,3 %. In group 2 with 1569 patients we found 318 (20.3%) carcinomas, PTC in 302 (94.6%) cases. The MPTC accounted for 215 (67.4%) cases. 10 patients with MPTC underwent hemithyroidectomy only. Numbers of central and lateral lymphadenectomies rose to 52 and 24 respectively. We gathered 376 lymph nodes with proven metastasis in 44.4% of these nodes. CONCLUSION: Both, the incidence and the frequency of PTC and MPTC are rising in our region. However, the number of less invasive procedures is not increasing significantly despite representing a sufficient way of treatment. We need wider adoption of these evidence-based recommendations by indicating endocrinologists in the Czech Republic.