Evaluation of the AJCC Eighth-Edition Prognostic Staging System for Breast Cancer in a Latin American Cohort.

BACKGROUND: The staging of breast cancer has been based on tumor size, lymph node involvement, and presence or absence of distant metastases. The American Joint Committee on Cancer (AJCC) staging system in its eighth edition incorporates hormone receptors, human epidermal growth factor receptor 2 (HER2), and histologic grade due to their prognostic importance. In Latin America, however, the impact of the new edition is unknown. This article evaluates the performance of the AJCC eighth-edition staging system in a cohort of patients with breast cancer at a reference center in Colombia. METHODS: The study investigated a descriptive cohort of 912 patients who received complete treatment for non-metastatic invasive breast cancer and had information on the anatomic stage and biologic factors,. All the patients were restaged using the AJCC eighth-edition classification. Changes in clinical stages and differences between the two classifications were compared. RESULTS: The study enrolled 912 patients. Changes in staging occurred for 54.82% (downstaging for 40.3% and upstaging for 14.47%) of these patients. For recurrence-free survival, the C-Index of the eighth-edition AJCC was 0.726, and the AIC was 1323.7, whereas the C-Index of the seventh-edition AJCC was 0.731, and the AIC was 1314.3 (p = 0.99). CONCLUSIONS: The seventh and eighth editions of the AJCC staging system have similar predictive values in our population for recurrence-free survival. Future studies are necessary to evaluate the performance of the AJCC eighth-edition staging system in predicting overall survival.

Eccrine Porocarcinoma with Zosteriform Metastasis.

Eccrine porocarcinoma is a rare malignant tumor that develops in the eccrine glands, appearing as a primary tumor, or by malignant transformation of an eccrine poroma. It is a carcinoma with high metastatic and recurrent potential; it has the same incidence in both sexes, and mainly affects the elderly. Its diagnosis, rather than clinical, is histological, and due to the rarity of the disease, it is a pathological challenge. There are no standardized treatment guidelines for porocarcinoma, but surgical resection with tumor-free margins is considered the basis of treatment, in addition to sentinel node biopsy under risk factors and individualization of each patient. For the metastatic form, chemotherapy and radiotherapy are the treatment of choice. Herein, we present the case of a man with eccrine porocarcinoma with extensive zosteriform skin metastasis and lymph node involvement, treated with chemotherapy and concomitant radiotherapy.

Medical Challenge Posed by Retroperitoneal Fibrosis: Case Reports and Literature Review.

Idiopathic retroperitoneal fibrosis (RPF) is a rare fibro-inflammatory disease, with a low incidence worldwide, which occurs around the abdominal aorta and the iliac arteries. It spreads through the retroperitoneum causing ureteral obstruction with associated renal failure and obstruction of other adjacent structures. RPF can be idiopathic or secondary to neoplastic processes, infections, or medications. RPF is considered part of the spectrum of the disease related to immunoglobulin G4 (IgG4) and other autoimmune disorders. Occupational exposure to asbestos and tobacco smoke are important risk factors for the development of idiopathic RPF. The clinical picture is nonspecific, from pain to symptoms due to ureteral compression, this being the main complication associated. Imaging studies are essential in the diagnosis; computed tomography (CT) and magnetic resonance imaging (MRI) are the most reliable imaging modalities. The goal of treatment is to stop the progression of the fibroinflammatory reaction. The first line of treatment is usually with medical management. Biological agents, such as rituximab and infliximab, have also been used, even with scarce data in the literature. Surgery is usually performed to improve a ureteral obstruction and should always be accompanied by systemic steroid treatment. The conservative approach given by systemic therapy and ureteral stent placement or nephrostomies has been recommended, thus reserving surgical treatment for refractory cases. We present two clinical cases of idiopathic RPF, one of them associated with IgG4.

Intraoperative combination of resuscitative endovascular balloon occlusion of the aorta and a median sternotomy in hemodynamically unstable patients with penetrating chest trauma: Is this feasible?

BACKGROUND: Recent evidence suggests that resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective life-saving intervention in patients with severe torso trauma. However, the deployment of REBOA in patients with isolated penetrating intrathoracic injuries remains controversial. We propose that a median sternotomy be performed in conjunction with REBOA as a feasible and effective means of hemorrhage control in patients suffering from penetrating chest trauma who present hemodynamically unstable. The objective of our study was to present our initial experience with this approach. METHODS: A prospectively collected case series of the use of REBOA (10 Fr) in conjunction with a median sternotomy from January 2015 to December 2016 at a Level I Trauma Center. We included hemodynamically unstable non-compressible torso hemorrhage patients with penetrating chest trauma who underwent intraoperative REBOA deployment plus median sternotomy. RESULTS: A total of 68 trauma-related emergent thoracic surgeries were performed at our institution during the study period. Of these, seven suffered from penetrating chest trauma and non-compressible torso hemorrhage and underwent REBOA plus median sternotomy. Six out of the seven patients suffered intrathoracic vascular injuries: two subclavian arteries, two internal mammary arteries, two aortic arch, and five major central venous injuries. Four patients had an associated lung injury with AIS >3, of which two suffered a pulmonary hilar vessel disruption. REBOA-related complications included one case of upper gastrointestinal bleeding. Six out of the seven patients survived the 30-day follow-up. No adverse neurologic outcomes or deficits were observed in survivors. CONCLUSION: The combined use of REBOA and median sternotomy could be a feasible and effective alternative to hemorrhage control in patients with non-compressible torso hemorrhage secondary to penetrating chest trauma. These findings challenge the recommendation against the use of REBOA in penetrating intrathoracic injuries. Future studies with stronger designs and larger sample sizes are required to confirm our results. LEVEL OF EVIDENCE: Therapeutic, level V.

Computed tomography in hemodynamically unstable severely injured blunt and penetrating trauma patients.

BACKGROUND: Dynamic and efficient resuscitation strategies are now being implemented in severely injured hemodynamically unstable (HU) patients as blood products become readily and more immediately available in the trauma room. Our ability to maintain aggressive resuscitation schemes in HU patients allows us to complete diagnostic imaging studies before rushing patients to the operating room (OR). As the criteria for performing computed tomography (CT) scans in HU patients continue to evolve, we decided to compare the outcomes of immediate CT versus direct admission to the OR and/or angio suite in a retrospective study at a government-designated regional Level I trauma center in Cali, Colombia. METHODS: During a 2-year period (2012-2013), blunt and penetrating trauma patients (≥ 15 years) with an Injury Severity Score (ISS) greater than 15 who met criteria of hemodynamic instability (systolic blood pressure [SBP] <100 mm Hg and/or heart rate >100 beats/min and/or ≥ 4 U of packed red blood cells transfused in the trauma bay) were included. Isolated head trauma and patients who experienced a prehospital cardiac arrest were excluded. The main study outcome was mortality. RESULTS: We reviewed 171 patients. CT scans were performed in 80 HU patients (47%) immediately upon arrival (CT group); the remaining 91 patients (53%) went directly to the OR (63 laparotomies, 20 thoracotomies) and/or 8 (9%) to the angio suite (OA group). Of the CT group, 43 (54%) were managed nonoperatively, 37 (46%) underwent surgery (15 laparotomies, 3 thoracotomies), and 2 (5%) underwent angiography (CT OA subgroup). None of the mortalities in the CT group occurred in the CT suite or during their intrahospital transfers. CONCLUSION: There was no difference in mortality between the CT and OA groups in HU patients. CT scan was attainable in 47% of HU patients and avoided surgery in 54% of the cases. Furthermore, CT scan was helpful in deciding definitive/specific surgical management in 46% scanned HU patients who necessitated surgery after CT. LEVEL OF EVIDENCE: Therapy/care management study, level IV.