Axillary evaluation in ductal cancer in situ of the breast: challenging the diagnostic accuracy of clinical practice guidelines.

BACKGROUND: Staging of the axilla is not routine in ductal cancer in situ (DCIS) although invasive cancer is observed in 20-25 per cent of patients at final pathology. Upfront sentinel lymph node dissection (SLND) is advocated in clinical practice guidelines in certain situations. These include expected challenges in subsequent SLN detection and when the risk for invasion is high. Clinical practice guidelines are, however, inconsistent and lead to considerable practice variability. METHODS: Clinical practice guidelines for upfront SLND in DCIS were identified and applied to patients included in the prospective SentiNot study. These patients were evaluated by six independent, blinded raters. Agreement statistics were performed to assess agreement and concordance. Receiver operating characteristic curves were constructed, to assess guideline accuracy in identifying patients with underlying invasion. RESULTS: Eight guidelines with relevant recommendations were identified. Interobserver agreement varied greatly (kappa: 0.23-0.9) and the interpretation as to whether SLND should be performed ranged from 40-90 per cent and with varying concordance (32-88 per cent). The diagnostic accuracy was low with area under the curve ranging from 0.45 to 0.55. Fifty to 90 per cent of patients with pure DCIS would undergo unnecessary SLNB, whereas 10-50 per cent of patients with invasion were not identified as 'high risk'. Agreement across guidelines was low (kappa = 0.24), meaning that different patients had a similar risk of being treated inaccurately. CONCLUSION: Available guidelines are inaccurate in identifying patients with DCIS who would benefit from upfront SLNB. Guideline refinement with detailed preoperative work-up and novel techniques for SLND identification could address this challenge and avoid overtreatment. LAY SUMMARY: The decision whether to operate on the axilla in women with a diagnosis of ductal cancer in situ (DCIS) is based on the risk of an undiagnosed underlying invasive cancer and on the concern that resection of the breast will not allow for accurate axillary mapping afterwards. Guidelines stem from older knowledge and are heterogeneous. In this study, different breast cancer guidelines were tested in a patient cohort from the SentiNot prospective trial for uniformity of interpretation and diagnostic accuracy. Results show that guidelines did not allow for easy and uniform interpretation and had the predictive ability of the toss of a coin. This suggests that guidelines regarding the need of axillary evaluation in patients operated for DCIS need to be revised and that techniques that will address the conundrum should be developed.

The decision whether to operate on the axilla in women with a diagnosis of ductal cancer in situ (DCIS) is based on the risk of an undiagnosed underlying invasive cancer and on the concern that resection of the breast will not allow for accurate axillary mapping afterwards. Guidelines stem from older knowledge and are heterogeneous. In this study, different breast cancer guidelines were tested in a patient cohort from the SentiNot prospective trial for uniformity of interpretation and diagnostic accuracy. Results show that guidelines did not allow for easy and uniform interpretation and had the predictive ability of the toss of a coin. This suggests that guidelines regarding the need of axillary evaluation in patients operated for DCIS need to be revised and that techniques that will address the conundrum should be developed.

Microbe Isolation from Blood, Central Venous Catheters, and Fluid Collections after Liver Resections.

BACKGROUND: Our goal was to evaluate the microbe species responsible for bacteremia or infections related to central venous catheter (CVC) or fluid collections after liver resection. PATIENTS AND METHODS: Data from 112 patients (68 males, 44 females) who underwent liver resection over a period of 63 months were reviewed. Patient and tumor characteristics, intra-operative and post-operative data, and the results from cultures of peripheral blood, CVC tips and drained intra-abdominal or intra-throracic fluid collections were collected. RESULTS: There were positive blood cultures in 20 patients (17.9%). Coagulase-negative staphylococci (CoNS) and bacteria of enteric flora were the micro-organisms found most frequently and half of the cases had multiple isolated microbe species. The construction of a bilioenteric anastomosis was an independent risk factor for microbe isolation in peripheral blood (odds ratio [OR]: 11, p = 0.01). Furthermore, there were positive cultures of the CVC tip in 14 patients (12.5%), with CoNS being the micro-organism found most frequently and most cases had only one isolated microbe species. No specific risk factor for catheter-related infections was detected. In addition, there were positive cultures of drained fluid collections in 19 patients (17%), with bacteria of enteric flora being the micro-organisms found most frequently and the majority of cases had multiple isolated microbe species. The construction of a bilioenteric anastomosis (OR: 23.5, p = 0.002) and the laparoscopic approach (OR: 4.7, p = 0.0496) were independent risk factors for microbe isolation in drained fluid collections. Finally, the presence of positive blood cultures was associated with the presence of positive culture of CVC tips (p = 0.018) and drained fluid collections (p = 0.001). CONCLUSIONS: Post-operative bacteremia, colonization of CVCs, and contamination of fluid collections occur frequently after liver resections and various microbe species may be involved. Patients who undergo hepatectomy and a synchronous construction of a bilioenteric anastomosis are at increased risk of bacteremia development and contamination of fluid collections.

Controversies and recommendations regarding sentinel lymph node biopsy in primary breast cancer: A comprehensive review of current data.

In primary breast cancer, sentinel lymph node biopsy has been established as the gold standard for regional axillary staging. A robust body of randomized data support its accuracy and safety in patients with early, clinically node negative disease. However, the role of SLNB remains debatable in various patient subgroups, and recent advances in histopathology, dedicated axillary ultrasound imaging and chemotherapy regimens, put its role under a new perspective. Herein, we review the current literature data on the indications for SLNB and discuss the challenges in management germane to special patient subgroups and patterns of disease. We also present emerging data on the optimal management of the SLN+ patient, in light of recent trials challenging the dogma of completion axillary dissection after a positive sentinel node biopsy.

The "Yin and Yang" of Platelet-rich Plasma in Breast Reconstruction After Mastectomy or Lumpectomy for Breast Cancer.

Surgery remains the mainstay of treatment for breast cancer, including complete or partial mastectomy and lumpectomy. Breast reconstruction has gained popularity mainly due to its tremendous impact on the psychological status of the patients. Autologous fat grafting is a well-established method used in cosmetic surgery; however, fat re-absoprtion, fat necrosis, calcifications and oil-cyst formation are some usually encountered complications limiting the efficacy of this approach. Platelet-rich plasma (PRP) has recently been postulated as a promising method for tissue regeneration since it contains high levels of diverse human growth factors. To date, preliminary results from clinical studies regarding the combination of PRP and fat grafting in breast reconstruction have shown ambiguous results, whereas preclinical studies are more favorable. However, concerns have been raised regarding the extent of cellular promotion induced by PRP application and the corresponding potential malignant transformation. The aim of our study was to present, analyze and critically evaluate the role of PRP in breast reconstruction after breast cancer surgery in terms of efficacy and oncological safety highlighting the caution that needs to be taken in order to eliminate any chance of recurrence in patients who have theoretically undergone complete excision of the tumor burden.

Current margin practice and effect on re-excision rates following the publication of the SSO-ASTRO consensus and ABS consensus guidelines: a national prospective study of 2858 women undergoing breast-conserving therapy in the UK and Ireland.

INTRODUCTION: There is variation in margin policy for breast conserving therapy (BCT) in the UK and Ireland. In response to the Society of Surgical Oncology and American Society for Radiation Oncology (SSO-ASTRO) margin consensus ('no ink on tumour' for invasive and 2 mm for ductal carcinoma in situ [DCIS]) and the Association of Breast Surgery (ABS) consensus (1 mm for invasive and DCIS), we report on current margin practice and unit infrastructure in the UK and Ireland and describe how these factors impact on re-excision rates. METHODS: A trainee collaborative-led multicentre prospective study was conducted in the UK and Ireland between 1st February and 31st May 2016. Data were collected on consecutive BCT patients and on local infrastructure and policies. RESULTS: A total of 79 sites participated in the data collection (75% screening units; average 372 cancers annually, range 70-900). For DCIS, 53.2% of units accept 1 mm and 38% accept 2-mm margins. For invasive disease 77.2% accept 1 mm and 13.9% accept 'no ink on tumour'. A total of 2858 patients underwent BCT with a mean re-excision rate of 17.2% across units (range 0-41%). The re-excision rate would be reduced to 15% if all units applied SSO-ASTRO guidelines and to 14.8% if all units followed ABS guidelines. Of those who required re-operation, 65% had disease present at margin. CONCLUSION: There continues to be large variation in margin policy and re-excision rates across units. Altering margin policies to follow either SSO-ASTRO or ABS guidelines would result in a modest reduction in the national re-excision rate. Most re-excisions are for involved margins rather than close margins.

Early Experience in Starting a Laparoscopic Liver Resection Program in Greece.

BACKGROUND AND OBJECTIVES: Laparoscopic liver resections (LLRs) have gained wider acceptance during the decade as safe and efficient procedures in the management of several benign and malignant diseases when performed by experienced surgeons. We report our initial institutional experience with LLRs performed by 1 certified hepatobiliary surgeon. METHODS: Patients undergoing LLRs by 1 senior hepatobiliary surgeon in our Institution during the period from January 2012 through January 2017 were prospectively sampled and retrospectively analyzed for the purposes of this study. RESULTS: Forty-two of 175 patients (24%) who had surgery for liver tumors underwent LLR. Median age was 64 years; median body mass index and Charlson comorbidity index were 27.3 kg/m2 and 6.5, respectively. Patients underwent resections for benign (n = 22) or malignant (n = 20) lesions. Median total operating time was 115 minutes and liver resections included: 1 left hepatectomy, 11 bisegmentectomies, 7 segmentectomies, 5 wide wedge resections, 1 left lateral sectionectomy combined with segmentectomy and radiofrequency ablation, 15 liver cyst unroofing, 1 laparoscopic drainage of a pyogenic liver abscess, and 1 laparoscopic drainage of a hepatic hydatid cyst. Blood transfusion was needed in 10 patients. Six patients (14%) had postoperative complications, none of which necessitated reoperation. None of the patients was admitted to the intensive care unit after surgery, and the median hospital stay was 4 days. The tumor-free resection margin was documented in all primary or secondary oncologic cases. CONCLUSIONS: Careful patient selection and compliance with the international recommendations are the keys for the successful introduction and evolution of an LLR program with a certified hepatobiliary surgeon with laparoscopic experience.

The value of staging laparoscopy in gastric cancer.

Treatment options for patients with gastric cancer (GC) are based on tumor staging and resectability. Although only surgery provides improved survival, resection is contraindicated and should be avoided in the presence of intra-abdominal disease stage M1 (liver, peritoneal, or non-local lymph node metastases). Thus, a detailed and precise evaluation is imperative for optimal treatment. Staging laparoscopy (SL) constitutes a major tool in the accurate diagnosis of several types of cancers, including GC. SL presents several critical advantages: it can diagnose intra-abdominal disease; serve as a complement to other imaging studies; allow for biopsies; facilitate intraoperative ultrasound evaluations; allow for sampling of peritoneal fluid for cytological examination; and serve as an option for the administration of intraperitoneal chemotherapy. Although considered and advocated as a very useful asset in the pre-treatment cancer-staging arsenal, the wider application of SL has been long debated. The purpose of our study was to evaluate the contribution of laparoscopy to GC staging.

Blue dye for identification of sentinel nodes in breast cancer and malignant melanoma: a systematic review and meta-analysis.

The combined technique (radioisotope and blue dye) is the gold standard for sentinel lymph node biopsy (SLNB) and there is wide variation in techniques and blue dyes used. We performed a systematic review and meta-analysis to assess the need for radioisotope and the optimal blue dye for SLNB. A total of 21 studies were included. The SLNB identification rates are high with all the commonly used blue dyes. Furthermore, methylene blue is superior to iso-sulfan blue and Patent Blue V with respect to false-negative rates. The combined technique remains the most accurate and effective technique for SLNB. In order to standardize the SLNB technique, comparative trials to determine the most effective blue dye and national guidelines are required.

Synchronous trifocal colorectal cancer.

Synchronous colorectal cancers (SCRCs) have been increasingly diagnosed due to emerging diagnostic modalities. The presence of three or more synchronous colorectal cancers has, however, only rarely been reported. A 76-year-old white man presented for management of two concurrent colorectal adenocarcinomas in the left colon evidenced on total colonoscopy. Preoperative abdominal ultrasonography and thoracoabdominal computed tomography were negative for metastatic disease. The patient underwent an elective left hemicolectomy. The pathology report ultimately showed the presence of three moderately differentiated, distinct colorectal cancers. The patient experienced an uneventful recovery.

Surgery for liver metastases from breast cancer.

INTRODUCTION: Liver metastases from breast cancer (BCLM) confer poor survival. Liver resection in BCLM patients has been increasingly employed. AIM: We undertook a systematic review to evaluate the role of hepatic resection in patients with breast cancer metastatic to the liver. MATERIALS & METHODS: In total, 36 studies were overviewed. Patient populations, characteristics, morbidity, mortality and survival were documented. RESULTS: Median overall survival was 41 months. Major morbidity was rare while 30-day postoperative mortality was near nil. CONCLUSION: Liver surgery for BCLM can be performed with low mortality, acceptable morbidity and promising survival benefit in carefully selected patients.

Inflammatory myofibroblastic tumor of the breast.

Inflammatory myofibroblastic tumors (IMTs) of the breast represent extremely rare lesions. Due to the scarcity of reports, their natural history, recurrence, and metastatic potential remain poorly defined. We report on a case of a primary breast IMT in a postmenopausal female patient treated successfully with breast conserving surgery and review the literature pertaining to this rare entity.

Emergency surgery for metastatic melanoma.

Visceral metastases from malignant melanoma (stage M1c) confer a very poor prognosis, as documented on the most recent revised version of the TNM/AJCC staging system. Emergency surgery for intra-abdominal complications from the disease is rare. We report on our 5-year single institution experience with surgical management of metastatic melanoma to the viscera in the emergent setting. From 2009 to 2013, 14 patients with metastatic melanoma were admitted emergently due to an acute abdomen. Clinical manifestations encompassed intestinal obstruction and bleeding. Surgical procedures involved multiple enterectomies with primary anastomoses in 8 patients, and one patient underwent splenectomy, one adrenalectomy, one right colectomy, one gastric wedge resection, one gastrojejunal anastomosis, and one transanal debulking, respectively. The 30-day mortality was 7 percent. Median follow-up was 14 months. Median overall survival was 14 months. Median disease free survival was 7.5 months. One-year overall survival was 64.2 percent and 2-year overall survival was 14.2 percent. Emergency surgery for metastatic melanoma to the viscera is rare. Elective curative surgery combined with novel cytotoxic systemic therapies is under investigation in an attempt to grant survival benefit in melanoma patients with visceral disease.

A Case of Retroperitoneal Castleman's Disease and an Update on the Latest Evidence.

Castleman's disease is a benign lymphoproliferative condition with three distinct histological subtypes. Clinically it presents in either a unicentric or multicentric manner and can affect various anatomic regions, the mediastinum being the most frequent location. We herein present a rare case of unifocal retroperitoneal mass proved to be hyaline vascular Castleman's disease. We perform a review of the current literature pertaining to such lesions, focusing on the management of the various clinical and histological variants of the disease. Surgical excision is the treatment of choice for unifocal Castleman's disease.

Primary enteric-type mucinous adenocarcinoma of the urethra in a patient with ulcerative colitis.

Primary carcinoma of the male urethra accounts for less than 1% of malignancies in men. Mucinous adenocarcinoma of the urethra is extremely rare, and its biologic behavior is poorly understood. We present herein a rare case of mucinous urethral adenocarcinoma in a male patient with longstanding ulcerative colitis and multiple sclerosis. The patient presented with a voluminous pelvic mass; core biopsy of the lesion demonstrated a mucus-producing adenocarcinoma. Given the patient's history of subtotal colectomy, preoperative diagnosis was oriented towards a rectal stump adenocarcinoma. The patient underwent a pelvic exenteration: surprisingly, histology marked the prostatic urethra as the primary lesion site.

Surgery for giant primary neuroendocrine carcinoma of the liver.

Liver resection for primary hepatic neuroendocrine carcinoma (phNEC) has only scarcely been reported in the literature. We herein report on a 19-year-old female with a solitary 27 × 13-cm-big phNEC, which was initially considered as hemangioma. An extended right hepatectomy (segments V-VIII, partially IVa) was performed. Resection margins were free of tumor (R0 resection). Ki67 expression was 35%. Postoperative course was uneventful, and the patient was discharged on the seventh postoperative day. Two years after surgery, the patient remains disease-free and in good general condition. Large series and longer follow-up studies are required for the better understanding on this rare tumor entity.