Factores predictivos de metástasis en ganglios no centinela en el cáncer de mama con ganglio centinela positivo / Predictive factors of non-sentinel lymph node disease in breast cancer patients with positive sentinel lymph node Mariana Peyroteo

Introducción: Manejo del ganglio centinela positivo en cáncer de mama sigue siendo un tema de debate. El objetivo es evaluar la incidencia e identificar los factores predictivos de metástasis en ganglios no centinela. Métodos: Revisión retrospectiva de los pacientes con cáncer de mama con axila clínicamente negativa (cN0) tratados entre enero del 2013 y diciembre del 2017, con biopsia de ganglio centinela (BGC) positiva a quienes se les realizó linfadenectomía axilar (LA). Resultados: De los 328 pacientes incluidos, la mayoría tenía tumores cT1 o cT2, con invasión linfovascular en el 58,4% de casos. La media de ganglios detectados en BGC fue 2,7, con una media de 1,6 ganglios positivos, el 60,7% con extensión extracapsular. En LA, una media de 13,9 ganglios fueron detectados, con media de 2,1 ganglios positivos. No se observó metástasis en LA en el 50,9% de los pacientes y el 18,9% tenía ≥ cuatro ganglios positivos. En análisis multivariado, la invasión linfovascular, la extensión extracapsular, la dimensión de mayor metástasis (>10 mm) y la ratio de ganglios centinela positivos (> 50%) fueron factores predictivos independientes de metástasis en ganglios no centinela. Estos factores fueron usados para construir un score para predecir la posibilidad de LA positiva después de BGC positiva. El área bajo la curva ROC (AUC) del modelo fue 0,69 y el 81% de los pacientes con score = 0, y el 65,6% con score = 1 no tenían metástasis en la LA. Conclusión: La ausencia de metástasis en ganglios no centinela en la mayoría de los casos con uno a dos ganglios positivos en la BGC con score de bajo riesgo cuestiona la necesidad de hacer LA en estos pacientes. Los factores predictivos identificados pueden ayudar a seleccionar pacientes para omitir la LA (AU)

Introduction: Management of positive sentinel lymph node biopsy (SLNB) in breast cancer remains a matter of debate. Our aim was to evaluate the incidence and identify predictive factors of non-sentinel lymph node metastases. Methods: Retrospective review of all cN0 breast cancer patients treated between January 2013 and December 2017, with positive SLNB that were submitted to ALND.ResultsOf the 328 patients included, the majority of tumors were cT1 or cT2, with lymphovascular invasion in 58.4% of cases. The mean isolated nodes in SLNB was 2.7, with a mean of 1.6 positive nodes, 60.7% with extracapsular extension. Regarding ALND, a mean of 13.9 nodes were isolated, with a mean of 2.1 positive nodes. There was no residual disease in the ALND in 50.9% of patients, with 18.9% having ≥ four positive nodes. In the multivariate analysis, lymphovascular invasion, extracapsular extension in SLN, largest SLN metastases size (>10 mm) and ratio of positive SNL (> 50%) were independent predictors of non-sentinel lymph node metastases. These four factors were used to build a non-pondered score to predict the probability of a positive ALND after a positive SLNB. The AUC of the model was 0.69 and 81% of patients with score = 0 and 65.6% with score = 1 had no additional disease in ALND. Conclusion: The absence of non-sentinel lymph node metastases in the majority of patients with 1-2 positive SLN with low risk score questions the need of ALND in this population. The identified predictive factors may help select patients in which ALND can be omitted (AU)

Tailgut cyst adenocarcinoma

Tailgut cysts (TGCs) are rare congenital entities arising from remnants of the embryological postanal primitive gut. Malignancy in TGCs is rare, with the majority being adenocarcinomas and carcinoid tumors. A search of the published literature yielded only 27 cases of adenocarcinoma developing in TGCs. We described the case of a 54-year-old female who presented with complaints of pelvic and perineal pain of several weeks. After the initial work-up, a mass in the right presacral location was diagnosed. She underwent radical resection of the tumor, using a posterior approach. The lesion was removed en bloc with the middle rectum, coccyx, and sacrum (S4­S5). The histopathologic examination revealed an adenocarcinoma arising in a TGC, and the patient received adjuvant chemoradiotherapy. Our case underlines that diagnosing a TGC is difficult as it is a rare congenital lesion. Clinical examination may be challenging as TGCs present with various symptoms, which can mimic other commonly proctologic disorders. Patients should be referred to a tertiary center with experience in pelvic surgery and must be managed by a multidisciplinary approach to maximize successful treatment. The recommended treatment is surgical excision given the malignant potential of TGCs and their risk of causing local complications.

Basal cell carcinoma: multimodal treatment and the role of neoadjuvant vismodegib

Basal cell carcinoma (BCC) is the most common skin cancer. It generally has an indolent course with low rates of metastasis and mortality. However, BCC is locally invasive and can cause significant morbidity due to destructive local spread. We report our experience with a patient who was referred to our skin cancer unit due to a previously neglected lesion on the parietal region of the scalp, which had developed for 7 years. The patient was prescribed vismodegib on the basis that surgery could cause excessive functional and aesthetic damage. The patient had an objective partial response after 20 months of treatment. He was then submitted to radical skin excision, leaving a large defect that was reconstructed using a free latissimus dorsi muscle flap. The patient recovered well, and at the 1-year follow-up there were no signs of local recurrence. Our case demonstrates the value of vismodegib treatment prior to surgery in a locally advanced, high-risk scalp BCC and highlights the importance of an individualized and specialized approach with these patients, within a multidisciplinary team.