P53 expression correlates with low axillary tumor burden in breast cancer.

BACKGROUND: The p53 mutation in breast cancer confers a worse prognosis and is usually associated with p53 overexpression (p53+) on immunohistochemistry. Previous studies have shown that p53+ tumors could be associated with low axillary tumor burden (ATB). OBJECTIVE: We aimed to evaluate the association between p53+ and ATB in a large series of breast cancers as an aid to personalizing axillary surgical treatment. METHODS: We retrieved 1762 infiltrating breast carcinomas from our database that were treated with upfront surgery in Hospital del Mar from 2004 to 2018. We compared p53+ and p53-negative (p53-) tumors in terms of the percentage of cases with high ATB and overall survival. This comparison was made overall and for each immunophenotype. RESULTS: Overall, 18.7% of breast tumors were p53+. High ATB was less common in p53+ tumors than in p53- tumors in the luminal B-Her2-negative immunophenotype (6.2% versus 16.9%, respectively, P = 0.025), but not in the other immunophenotypes or overall. Overall survival was worse in patients with p53+ breast cancer (P = 0.002). CONCLUSION: p53+ breast cancers were associated with worse overall survival. However, low ATB was more common in these tumors than in p53- tumors in the luminal B-Her2-negative subtype. Information on p53 expression could be of use to predict ATB in some breast cancer tumors.

Validation of the Spanish electronic version of the BREAST-Q questionnaire.

BACKGROUND: Patient-reported outcome measures (PROMs) have gained considerable interest in health care moving beyond traditional outcome measures of morbidity and mortality. In breast cancer surgery, women's' perceptions of appearance, function and quality of life have become increasingly important. The BREAST-Q questionnaire is a validated PROM for use in cosmetic and reconstructive breast surgery in clinical practice. The objective of this study was to validate the Spanish electronic version of the BREAST-Q questionnaire, to verify the measurement equivalence of digital and paper versions and to identify the possible disadvantages and advantages of implementing this new tool. METHODS: The study population included 113 patients undergoing breast cancer survey at a single hospital in Barcelona (Spain) who were able to complete both the electronic and paper versions of the preoperative module of the BREAST-Q questionnaire. RESULTS: The intraclass correlation coefficient (ICC) in the four domains of the questionnaire between the two versions of the questionnaire was >0.9, with a weighted kappa of >0.74 at item level. The reliability of the internal consistency was also excellent, with Cronbach's alpha coefficient of >0.70 in all domains. Age was a limiting factor for the delivery of the electronic version of BREAST-Q, with 69 years of age as the cut-off point to obtain reliable results. CONCLUSIONS: The interchangeability of the electronic and paper versions of the BREAST-Q questionnaire facilitates implementation of this instrument in routine surgical oncological practice.

Accuracy of sentinel node mapping in patients with biopsy-proven metastatic axillary lymph nodes and upfront surgery: preliminary results of the Multimodal Targeted Axillary Surgery (MUTAS) trial.

Background: Some studies suggested that the patients included in the Z0011 trial may represent patients with ultrasound-negative axillary nodes and axillary invasion diagnosed by sentinel node (SN) biopsy. Nevertheless, the National Comprehensive Cancer Network (NCCN) guidelines recommend SN mapping if 1 or 2 suspicious lymph nodes are identified on axillary ultrasound (AU). The aim of this preliminary phase of the Multimodal Targeted Axillary Surgery (MUTAS) trial was to establish the accuracy of SN mapping in patients with axillary involvement undergoing upfront surgery. Methods: Between September 2019 and March 2022, we recruited patients with biopsy-proven metastatic axillary nodes and upfront surgery from a single center. We performed SN mapping in these patients before the surgical intervention, which included axillary lymph node dissection. The biopsy-proven metastatic node, SNs and the remaining axillary nodes were excised separately. SN status was considered representative of the status of the remaining axillary nodes. We calculated the sensitivity, specificity, negative predictive value and positive predictive value of the SN, overall and in patients with palpable nodes, in those with non-palpable nodes and an AU leading to diagnosis of axillary involvement, in those with 1 or 2 suspicious nodes on AU, and in patients with a single suspicious node on AU. We evaluated clinical, imaging and pathology features as predictors of the status of the remaining axillary nodes, false-negatives, and false-positives. Results: We included 25 patients in this phase. The false-negative rate of SN mapping was 28% overall, 21.42% for patients with palpable nodes, 36.36% for patients with non-palpable nodes and an AU diagnosis of axillary involvement, 28.75% for those with 1 or 2 suspicious nodes on AU, and 15.38% in patients with a single suspicious node on AU. The negative predictive value was highest in patients with a single suspicious node on AU (75%). The only significant predictive factor was that FN showed a higher Ki67 index score. Conclusions: In this study, SN mapping was not reliable in patients with biopsy-proven metastatic axillary nodes and upfront surgery for any of the subgroups studied. Further research should elucidate the best staging pathways in these patients to avoid premature de-escalation.

Impact of curative treatment on the physical fitness of patients with esophageal cancer: A systematic review and meta-analysis.

BACKGROUND: Esophageal cancer and curative treatment have a significant impact on the physical fitness of patients. Knowledge about the course of physical fitness during neoadjuvant therapy and esophagectomy is helpful to determine the needs for interventions during and after curative treatment. This study aims to review the current evidence on the impact of curative treatment on the physical fitness of patients with esophageal cancer. METHODS: A systematic literature search of PubMed, Embase, Cinahl and the Cochrane Library was conducted up to March 29, 2021. We included observational studies investigating the change of physical fitness (including exercise capacity, muscle strength, physical activity and activities of daily living) from pre-to post-neoadjuvant therapy and/or from pre-to post-esophagectomy. Quality of the studies was assessed and a meta-analysis was performed using standardized mean differences. RESULTS: Twenty-seven articles were included. After neoadjuvant therapy, physical fitness decreased significantly. In the first three months after surgery, physical fitness was also significantly decreased compared to preoperative values. Subgroup analysis showed a restore in exercise capacity three months after surgery in patients who followed an exercise program. Six months after surgery, there was limited evidence that exercise capacity restored to preoperative values. CONCLUSION: Curative treatment seems to result in a decrease of physical fitness in patients with esophageal cancer, up to three months postoperatively. Six months postoperatively, results were conflicting. In patients who followed a pre- or postoperative exercise program, the postoperative impact of curative treatment seems to be less.

Feasibility, tolerability, and effects of exercise-based prehabilitation after neoadjuvant therapy in esophagogastric cancer patients undergoing surgery: an interventional pilot study.

Patients requiring surgery for locally advanced esophagogastric cancer often require neoadjuvant therapy (NAT), which may have a detrimental impact on cardiorespiratory reserve. The aims of this study were to investigate the feasibility and tolerability of a 5-week preoperative high-intensity interval training program after NAT, and to assess the potential effects of the training protocol on exercise capacity, muscle function, and health-related quality of life (HRQL). We prospectively studied consecutive patients with resectable locally advanced esophageal and gastric cancer in whom NAT was planned (chemo- or chemoradiotherapy). Feasibility was assessed with the TELOS (Technological, Economics, Legal, Operational, and Scheduling) components, and data on exercise tolerability (attendance and occurrence of adverse or unexpected events). Exercise capacity was assessed with peak oxygen uptake (VO2peak) in a cardiopulmonary exercise test at baseline, post-NAT, and following completion of a high-intensity interval exercise training (25 sessions). Changes in muscle strength and HRQL were also assessed. Of 33 recruited subjects (mean age 65 years), 17 received chemoradiotherapy and 16 chemotherapy. All the TELOS components were addressed before starting the intervention; from a total of 17 questions considered as relevant for a successful implementation, seven required specific actions to prevent potential concerns. Patients attended a mean of 19.4 (6.4) exercise sessions. The predefined level of attendance (≥15 sessions of scheduled sessions) was achieved in 27 out of 33 (81.8%) patients. Workload progression was adequate in 24 patients (72.7%). No major adverse events occurred. VO2peak decreased significantly between baseline and post-NAT (19.3 vs. 15.5 mL/Kg/min, P < 0.05). Exercise led to a significant improvement of VO2peak (15.5 vs. 19.6 mL/kg/min, P < 0.05). Exercise training was associated with clinically relevant improvements in some domains of HRQL, with the social and role function increasing by 10.5 and 11.6 points, respectively, and appetite loss and fatigue declining by 16 and 10.5, respectively. We conclude that a structured exercise training intervention is feasible and safe following NAT in patients with esophagogastric cancer, and it has positive effects to restore exercise capacity to baseline levels within 5 weeks with some improvements in HRQL.

Diagnosis and locoregional treatment of patients with breast cancer during the COVID-19 pandemic / Diagnostico y tratamiento locorregional de las pacientes con cancer de mama durante la pandemia de la COVID-19

We are facing a pandemic that is going to affect a significant part of the population. At the end of April in the world there are about 3,000,000 cases, with 205,000 deaths and 860,000 patients recovered. The response to this pandemic has in many cases led to a significant change in the daily work of caring for cancer patients, the good results of which depend largely on time-adjusted protocols and multidisciplinary treatments. We present a review of local, surgical and radiotherapy treatment together with authors' recommendations made from personal experience on ways to act in the diagnosis and surgical treatment of breast cancer during the COVID-19 pandemic. The multidisciplinary Breast Committees must continue to meet weekly in videoconference format. All surgical actions and irradiations must be carried out with maximum safety for both the patients and the participating teams. Hypofractionation in radiation therapy should be the standard treatment. Sometimes it is recommended to apply a primary systemic treatment or even a primary irradiation. Great coordination between the surgical and oncology teams, both medical and radiotherapeutic, is essential

Nos enfrentamos a una pandemia que afecta a una parte importante de la población.  A finales de abril de 2020, en el mundo hay cerca de 3.000.000 de casos, con 205.000 muertes y 860.000 pacientes recuperados. La respuesta a esta pandemia en muchos casos ha supuesto modificaciones importantes en el cuidado diario de las pacientes con cáncer, dependiendo el buen resultado en buena parte del ajuste de los protocolos a las circunstancias especiales y a los tratamientos multidisciplinarios. Presentamos una revisión del tratamiento quirúrgico y radioterapia junto con las recomendaciones de los autores basadas en su experiencia personal a la hora del diagnóstico y tratamiento locorregional del cáncer de mama durante la pandemia del COVID-19. Los comités multidisciplinarios deben seguir reuniéndose semanalmente en formato de videoconferencia. Todos las intervenciones quirúrgicas e irradiaciones deben ser llevadas a cabo con la máxima seguridad tanto para las pacientes como para el personal sanitario que participa. El hipofraccionamiento debe ser el tratamiento radioterápico estándar. En algunos casos se utilizará tratamiento sistémico primario o incluso radioterapa preoperatoria. Es esencial una coordinación importante entre los equipos quirúrgicos y los oncológicos, tanto radioterápicos como médicos

El tatuaje endoscópico en las neoplasias colorrectales intervenidas vía laparoscópica: una propuesta de marcaje selectivo / Endoscopic tattooing of colorectal neoplasms removed by laparoscopy: a proposal for selective marking

Introducción y objetivo: el tatuaje endoscópico preoperatorio es un procedimiento eficaz que permite la localización intraoperatoria de neoplasias de pequeño tamaño. Sin embargo, actualmente no existen unos criterios definidos sobre las indicaciones del tatuaje endoscópico de estas neoplasias en el momento del diagnóstico. El objetivo es establecer unos criterios endoscópicos para seleccionar los pacientes que precisarán un tatuaje. Material y métodos: estudio ambispectivo de pacientes intervenidos de neoplasia colorrectal por laparoscopia en los que se realizó tatuaje endoscópico en el periodo (2007- 2013 y 2016-2017). De acuerdo con la descripción endoscópica de las neoplasias se clasificaron en: lesiones polipoideas, neoplasias que ocupan < 50% o ≥ 50% de la luz intestinal y neoplasias estenosantes. Resultados: se realizó tatuaje de la lesión en 120 pacientes y en 114 (95%) se identificó el mismo durante la cirugía. La mayor parte de las neoplasias descritas como polipoideas y neoplasias que ocupaban < 50% de la luz intestinal no se visualizaban en la cirugía y por tanto precisaban el tatuaje (33 de 42 y 18 de 26 respectivamente, p = 0.0001, χ2). En cambio, aquellas lesiones estenosantes o bien neoplasias que ocupaban ≥ 50% de la luz intestinal se identificaban mayoritariamente en la cirugía (15 de 15 y 36 de 37 respectivamente, p = 0.0001, χ2) sin necesidad de tatuaje. En conjunto la identificación de las neoplasias según los criterios establecidos fue del 98%. Conclusiones: estos resultados sugieren que es posible establecer unos criterios endoscópicos que permitan realizar un tatuaje selectivo durante la endoscopia diagnóstica manteniendo el éxito del mismo (AU)

Background and aim: Preoperative endoscopic tattooing is an effective procedure to identify small intraoperative neoplasms. However, there are no defined criteria with regard to the indications for endoscopic tattooing of these lesions at the time of diagnosis. The aim of this study was to establish endoscopic criteria that allow the selection of patients who will need a tattoo during the diagnostic colonoscopy. Methods: An ambispective study of patients undergoing laparoscopy due to a colorectal neoplasia who underwent endoscopic tattooing during the period from 2007-2013 and 2016-2017. According to the endoscopic description of the neoplasms, the classification was polypoid lesions, neoplasms occupying < 50% or ≥ 50% of the intestinal lumen and stenosing neoplasias. Results: Tattooing of the lesion was performed in 120 patients and the same lesions were identified during surgery in 114 (95%) cases. Most of the neoplasias described as polypoids and neoplasias that occupied < 50% of the intestinal lumen were not visualized during surgery and therefore required a tattoo (33 of 42 and 18 of 26 respectively, p = 0.0001, X2). On the other hand, stenosing lesions or neoplasias occupying ≥ 50% of the intestinal lumen were mostly identified during surgery (15 of 15 and 36 of 37 respectively, p = 0.0001, X2) without the need for a tattoo. Overall, the identification of neoplasms according to established criteria was 98%. Conclusion: These results suggest that it is possible to establish endoscopic criteria that allow a successful selective tattooing during diagnostic endoscopy (AU)

Endoscopic tattooing of colorectal neoplasms removed by laparoscopy: a proposal for selective marking.

BACKGROUND AND AIM: Preoperative endoscopic tattooing is an effective procedure to identify small intraoperative neoplasms. However, there are no defined criteria with regard to the indications for endoscopic tattooing of these lesions at the time of diagnosis. The aim of this study was to establish endoscopic criteria that allow the selection of patients who will need a tattoo during the diagnostic colonoscopy. METHODS: An ambispective study of patients undergoing laparoscopy due to a colorectal neoplasia who underwent endoscopic tattooing during the period from 2007-2013 and 2016-2017. According to the endoscopic description of the neoplasms, the classification was polypoid lesions, neoplasms occupying < 50% or ≥ 50% of the intestinal lumen and stenosing neoplasias. RESULTS: Tattooing of the lesion was performed in 120 patients and the same lesions were identified during surgery in 114 (95%) cases. Most of the neoplasias described as polypoids and neoplasias that occupied < 50% of the intestinal lumen were not visualized during surgery and therefore required a tattoo (33 of 42 and 18 of 26 respectively, p = 0.0001, X2). On the other hand, stenosing lesions or neoplasias occupying ≥ 50% of the intestinal lumen were mostly identified during surgery (15 of 15 and 36 of 37 respectively, p = 0.0001, X2) without the need for a tattoo. Overall, the identification of neoplasms according to established criteria was 98%. CONCLUSION: These results suggest that it is possible to establish endoscopic criteria that allow a successful selective tattooing during diagnostic endoscopy.

The use of an algorithm for prophylactic mesh use in high risk patients reduces the incidence of incisional hernia following laparotomy for colorectal cancer resection. / Un algoritmo para la colocación de malla profiláctica en pacientes de riesgo reduce la incidencia de hernia incisional tras laparotomía por cáncer colorrectal.

OBJECTIVE: Incisional hernia (IH) after colorectal surgery is highly prevalent. The objective of this study is to assess the utility of an algorithm to decide on mesh augmentation after a midline laparotomy for colorectal resection to prevent IH in high-risk patients. METHODS: A prospective study was conducted including all patients undergoing a midline laparotomy for colorectal resection between January 2011 and June 2014, after the implementation of a decision algorithm for prophylactic mesh augmentation in selected high-risk patients. Intention-to-treat analyses were conducted between patients in which the algorithm was correctly applied and those in which it was not. RESULTS: From the 235 patients analysed, the algorithm was followed in 166 patients, the resting 69 cases were used as a control group. From an initial adherence to the algorithm of 40% in the first semester, a 90.3% adherence was achieved in the seventh semester. The incidence of IH decreased as the adherence to the algorithm increased (from 28 to 0%) with a time-related correlation (R2=0.781). A statistically significant reduction in IH incidence was demonstrated in high-risk groups in which the algorithm was correctly applied (10,2 vs. 46,3%; p=0,0001; OR: 7,58;95%; CI: 3,8-15). Survival analysis showed that the differences remained constant during follow-up. CONCLUSION: The implementation of the algorithm reduces the incidence of IH in high-risk patients. The adherence to the algorithm also correlates with a decrease in the incidence of IH.

Un algoritmo para la colocación de malla profiláctica en pacientes de riesgo reduce la incidencia de hernia incisional tras laparotomía por cáncer colorrectal / The use of an algorithm for prophylactic mesh use in high risk patients reduces the incidence of incisional hernia following laparotomy for colorectal cancer resection

INTRODUCCIÓN: Existe una alta incidencia de hernia incisional (HI) tras cirugía de colon. El objetivo de este estudio fue analizar la utilidad de un algoritmo de decisión para la colocación de malla profiláctica tras laparotomía media por cáncer colorrectal en pacientes de riesgo. MÉTODOS: Se planteó un estudio prospectivo que incluyera a los pacientes intervenidos de cáncer colorrectal por laparotomía media entre enero de 2011 y junio de 2014, tras la implementación de un algoritmo de decisión para la colocación de malla profiláctica en pacientes seleccionados de alto riesgo. Se realizó análisis por intención de tratar entre los pacientes en los que se siguió correctamente el algoritmo y en los que no. RESULTADOS: De los 235 pacientes analizados, el algoritmo se siguió correctamente en 166 pacientes, los 69 restantes se usaron como grupo control. Partiendo de una adherencia inicial del 40% en el primer semestre del estudio, se logró llegar a un cumplimiento del 90,3% en el último semestre. La incidencia de HI disminuyó progresivamente a medida que aumentaba la adherencia (de 28 a 0%), con una correlación tiempo-dependiente (R2=0,781). Se logró una disminución estadísticamente significativa de HI en los grupos en los que el algoritmo se aplicó correctamente (10,2 vs. 46,3%; p = 0,0001; OR 7,58;95% IC: 3,8-15). El análisis de supervivencia demostró que las diferencias se mantuvieron constantes durante el seguimiento. CONCLUSIONES: La implementación del algoritmo redujo la incidencia de HI en pacientes de riesgo. La adherencia al algoritmo se correlaciona con el descenso en la incidencia de HI

OBJECTIVE: Incisional hernia (IH) after colorectal surgery is highly prevalent. The objective of this study is to assess the utility of an algorithm to decide on mesh augmentation after a midline laparotomy for colorectal resection to prevent IH in high-risk patients. METHODS: A prospective study was conducted including all patients undergoing a midline laparotomy for colorectal resection between January 2011 and June 2014, after the implementation of a decision algorithm for prophylactic mesh augmentation in selected high-risk patients. Intention-to-treat analyses were conducted between patients in which the algorithm was correctly applied and those in which it was not. RESULTS: From the 235 patients analysed, the algorithm was followed in 166 patients, the resting 69 cases were used as a control group. From an initial adherence to the algorithm of 40% in the first semester, a 90.3% adherence was achieved in the seventh semester. The incidence of IH decreased as the adherence to the algorithm increased (from 28 to 0%) with a time-related correlation (R2=0.781). A statistically significant reduction in IH incidence was demonstrated in high-risk groups in which the algorithm was correctly applied (10,2 vs. 46,3%; p = 0,0001; OR: 7,58;95%; CI: 3,8-15). Survival analysis showed that the differences remained constant during follow-up. CONCLUSION: The implementation of the algorithm reduces the incidence of IH in high-risk patients. The adherence to the algorithm also correlates with a decrease in the incidence of IH

Prophylactic synthetic mesh can be safely used to close emergency laparotomies, even in peritonitis.

BACKGROUND: This study was conducted to determine the efficacy and safety of the use of a partially absorbable large pore synthetic prophylactic mesh in emergent midline laparotomies for the prevention of evisceration and incisional hernia. METHODS: Retrospective analysis of all patients who underwent an emergency midline laparotomy between January of 2009 and July of 2010 was performed. Patients with complicated ventral hernia repair, postoperative death, and lack of follow-up were excluded. RESULTS: A total of 266 patients were included. Laparotomies were closed with a running suture of slow-reabsorbable material in 190 patients (Group S), and 50 patients within this group (26.3%) received additional retention sutures. In 76 patients (Group M), an additional partially absorbable lightweight mesh was placed in the Supra-aponeurotic space. Both groups presented similar complication rates (71.1% Group S vs 80.3% Group M, P = .97). There were no differences regarding surgical-site infection rates (17.9% Group S vs 26.3% Group M; P = .13) or postoperative mortality (13.7% Group S vs 18.3% Group M; P = .346). A total of 150 patients completed the follow-up (99 Group S; 51 Group M) at a mean time of 16.7 months. During follow-up, 36 cases of incisional hernia (24%) were diagnosed: 33 (33%) in Group S, whereas there were only three cases (5.9%) in Group M (P = .0001). Mesh removal for chronic infection was not required in any case. CONCLUSION: The use of a partially absorbable, lightweight large pore prophylactic mesh in the closure of emergency midline laparotomies is feasible for the prevention of incisional hernia without adding a substantial rate of morbidity to the procedure, even if high contamination or infections are present.