Can Skin Sparing Mastectomy and Immediate Submuscular Implant-Based Reconstruction Be a Better Choice in Treatment of Early-Stage Breast Cancer?

OBJECTIVE: To discuss if skin sparing mastectomy (SSM) with immediate submuscular implant-based reconstruction (IBR) can be the preferred treatment in early-stage breast cancer. MATERIALS AND METHODS: Patients treated for clinical in situ or early-stage invasive breast cancer with SSM and immediate submuscular IBR between October 2016 and October 2018 were retrospectively evaluated. RESULTS: Twenty-one cases were reviewed, of whom18 had two-stage and three had one-stage IBR. Median (range) follow-up period was 42 (32-61) months. Five underwent axillary dissection and 1-2 metastatic nodes were found in three (60%). Eight patients (38.09%) with two-stage IBR had radiotherapy because of upstaging and three (37.5%) experienced radiotherapy-linked complications. Rate of complications and mean number of events recorded per patient were higher with radiotherapy. Four patients (44%) had unwanted events after secondary surgery. The mean number of surgeries was higher after two-stage IBR. Mean duration increased in those with chemo-radiotherapy. Six with two-stage and two with one-stage IBR discontinued secondary surgeries. CONCLUSION: SSM with immediate submuscular IBR is not suitable in all patients with early-breast cancer. It takes long to have aesthetically pleasing, symmetrical breasts after primary operation because of additional corrective/matching surgeries. Radiotherapy may still be required because of upstaging. Expectation and tolerability of the patient to the process should be evaluated as well as tumor biology and the status of the axilla.

Peritoneal dialysis for refractory heart failure: A single-center experience.

INTRODUCTION: Heart failure (HF) is a disease associated with poor quality of life. Peritoneal dialysis (PD) can be an alternative in the treatment of these patients to overcome fluid overload. The objective of this study is to observe the effects of PD in refractory HF patients. METHODS: We conducted an observational study including 10 patients with refractory congestive HF. PD started solely for fluid overload. Patients' baseline parameters were compared with follow-up parameters. RESULTS: Median age was 57.5 (44.8-64.3) years. Median left ventricular ejection fraction was 20% (18.8-31.3), and all patients had right ventricular dysfunction. Median estimated glomerular filtration rate was 51.2 (43.8-101.3) ml/min/1.73 m2 . Two patients (20%) died during the follow-up period. New York Heart Association (NYHA) functional class decreased significantly from a median of 4 to 2,1 and 1 in the 3rd, 6th, and 12th months, respectively (p ≤ 0.01 for all from baseline). Number and length of hospitalization decreased significantly after treatment (number from a median of 3 to 0, p = 0.013; days from 50.5 to 0, p = 0.028). CONCLUSION: PD significantly reduced NYHA functional class, number and days of hospitalization for HF. It could be a reasonable option in chronic treatment of patients with refractory HF.

Cinical Significance of Androgen Receptor, CK-5/6, KI-67 and Molecular Subtypes in Breast Cancer.

OBJECTIVE: To detect the relationship between molecular subtypes of breast cancer with expressions of androgen receptor, cytokeratin 5/6 (CK5/6)and Ki-67. MATERIALS AND METHODS: Expressions of androgen receptor, CK-5/6 and Ki-67 were determined by immunohistochemistry in paraffin-embedded sections obtained from 86 invasive breast cancer cases of stages I/IIa/IIb in 4 molecular subtypes. Patients treated for recurrent disease and locally advanced disease were excluded. RESULTS: Forty one luminal A cases, ie. positive estrogen receptor(ER) and/or progesteron receptor (PR) with negative epidermal growth factor receptor (HER2), 14 luminal B, ie. positive ER and/or PR and positive HER2, 14 HER2-enriched (HER2+), ie. negative ER and PR with positive HER2, and 17 triple negative (negative ER and PR and HER2) invasive breast cancers were included. Mean follow-up was 17.46±11.70 mo. Androgen receptor-negativity and CK5/6-positivity were significantly more common in HER2+ and triple negative groups. Ki-67 and histological grade were higher in HER2+ group, significantly. Two deaths were triple negative (P=0.04). Androgen receptor-negativity, CK5/6 and Ki-67 status did not affect survival or systemic metastases, significantly. All groups had local recurrences. Local recurrence was significantly associated with androgen receptor-negativity in luminal A and high Ki-67 value in HER2+ groups. Systemic metastases were significantly more common in triple negative and HER2+ groups. CONCLUSION: Molecular subtypes of breast cancer are prognostic and predictive. Androgen receptor is expressed more commonly in luminal subtypes with better prognosis and androgen receptor negativity is associated with development of local recurrence in luminal A cancers.

Incremental value of magnetic resonance imaging for breast surgery planning.

PURPOSE: The aim of this study was to evaluate the effect of breast magnetic resonance imaging (MRI) on preoperative or intraoperative surgical planning. METHODS: One hundred and sixty females with breast cancer were enrolled in the study. The contribution of MRI compared to MMG and USG, their histopathological concordance, and their impact on surgical treatment were evaluated prospectively. RESULTS: In 48 (30.0%) of the patients, MRI identified suspicious lesions that were not detected by MMG and USG. The diagnosis by MRI was accurate in 17 (10.6%) of them, while in remaining 31 patients (19.4%) the additional lesions found by MRI and interpreted as malignant were found not to be malignant. The pathological accordance of MRI and MMG compared with USG were 69.3 and 70.0%, respectively, whereas individually, MMG and USG were in accordance with the pathological examination in 52.9 and 67.9% of the cases, respectively. CONCLUSIONS: Assessment of the tumor size, multifocality, multicentricity, and presence of ductal carcinoma in situ by MRI may lead to misinterpretations in the majority of patients. The surgical approach should not be changed based solely on MRI findings. An accurately interpreted MMG combined with USG may be sufficient in most cases.

Effects of hemoperitoneum on wound healing and fibrinolytic activity in colonic anastomosis.

BACKGROUND: We aimed to test whether hemoperitoneum has adverse effects on colonic anastomosis healing by increasing fibrinolytic activity. METHODS: After colonic intersection and anastomosis, 20 Wistar Albino rats received intraabdominal injections of either 25 mg/kg blood (10, Group 1) or physiologic saline (10, Group 2). Anastomotic bursting pressures were measured after sacrifice on the fifth day. Following histopathological evaluation of the anastomotic line, hydroxyproline, tissue plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1), and tPA/PAI-1 complex levels were determined in the omentum, lung and anastomotic colon. RESULTS: Mean anastomotic bursting pressures of Groups 1 and 2 were 224.5 mmHg and 254.4 mmHg (p=0.121), and mean hydroxyproline levels were 45.89 and 65.959 mg/g protein, respectively (p=0.257). Histopathology was insignificant. There was a significant difference between groups in omental tPA levels (0.962 ng/ml and 0.27 ng/ml, p=0.041), but not in PAI-1 and tPA/PAI-1. Anastomotic line and lung levels of tPA, PAI-1 and tPA/PAI-1 complex were not significantly different between groups. The relation between anastomotic line tPA level and bursting pressure was highly significant in Group 2 (r=0.778; p=0.008). CONCLUSION: In this first study on the effect of hemoperitoneum on colonic anastomosis, we observed no significant effect on anastomotic healing or fibrinolytic activity, except in the omentum. Further studies with different blood volumes and assessment times are needed.

Management of Patients with Granulomatous Mastitis: Analysis of 31 Cases.

BACKGROUND: Granulomatous mastitis is a benign recurrent disease. Accurate diagnosis is only by histopathology. PATIENTS AND METHODS: 31 cases with histological diagnosis were retrospectively analyzed. RESULTS: Mean follow-up was 42.4 months for recurrent and 27.8 months for non-recurrent cases. Etiology was tuberculosis in 1 case. 5 cases (16%) relapsed. 6 patients (19.3%) treated with abscess drainage healed completely, but 50% relapsed. Relapses were treated with excision or steroids. Steroid therapy was the initial treatment in 12 cases (38.7%), with 1 relapse (8.3%) which was treated in the same manner. 2 patients had incomplete response necessitating excision, and another 2 developed abscesses which were treated with steroids or excision after drainage. Surgical excision was preferred in 12 cases (38.7%) due to suspicion for carcinoma in 8 patients (25.8%) and/or low probability of poor cosmetic outcome. All healed without complication, and recurrence was observed in 1 case (8.3%) which was treated with re-excision. CONCLUSION: Both excision and steroid therapy had low and similar relapse rates, but excision was superior to steroid therapy in providing strict diagnosis with much faster healing and fewer complications. In refractory cases, and when deformity is inevitable, steroid therapy should be preferred.

Predicting the likelihood of nonsentinel lymph node metastases in triple negative breast cancer patients with a positive sentinel lymph node: Turkish Federation of Breast Disease Associations protocol MF09-01.

BACKGROUND: Triple negative (TN) tumor has a relatively high rate of recurrence and distant metastasis, but results of studies revealed that triple positive tumor is an independent predictor of axillary lymph node involvement. Our aim was to evaluate the frequency of nonsentinel lymph node metastasis (NSLNM) involvement in operable TN breast cancer with positive sentinel lymph node (SLN) and predicting the likelihood of NSLNM in this cohort of patients by using 4 different nomograms. METHODS: A total of 128 patients with TN and SLN(+) underwent complete axillary lymph node dissection in 14 different centers in Turkey. For comparison, we used our previous multicenter MF08-01 Protocol, which identified 441 patients with estrogen receptor (ER(+)) who had a positive SLN biopsy and underwent subsequent complete axillary lymph node dissection. Turkish, Cambridge, and Stanford nomograms and the Tenon Score system were used to calculate the probability of NSLNM. RESULTS: Patients with TN tumor had a larger tumor size. The actual percentage of NSLN positivity was 41% in the TN group and 47.1% in patient with ER(+). The Tenon Score was ≤3.5 in 12% of patients with TN and ER(+); the area under the curve in the receiver operating characteristics curve were 0.53 and 0.59, respectively. Based on the Turkish, Cambridge, and Stanford nomograms, areas under the curve were 0.54, 0.53, and 0.61, respectively in patients with TN, and were 0.79, 0.72, and 0.70, respectively, in patients with ER(+). CONCLUSION: Using the Tenon Score system underestimates NSLN positivity, and tested nomograms are not good discriminators of NSLNM in patients with TN and positive SLN.

Gastric duplication cyst in an adult.

Gastric duplication cyst which is a rare anomaly can also be observed in adulthood. Abdominal pain is the most common complaint in adults and most cases are discovered incidentally by radiological examination or gastric endoscopy. Preoperative diagnosis of gastric duplication is difficult and definitive diagnosis requires findings on laparatomy together with histopathological examination of the lesion. Gastric duplication cyst is primarily managed by complete excision. Gastric duplication cyst was suspected on gastric endoscopy and magnetic resonance imaging (MRI) of the abdomen in a 52-year-old woman presented with abdominal pain. She was treated by complete excision of the cyst and the diagnosis was confirmed with the operative findings and histopathological examination of the removed specimen.

Ectopic breast carcinoma.

A 47-year-old premenopausal woman had a swelling in right axilla which had been diagnosed as "ectopic breast tissue" with an incisional biopsy. A subcutaneous nodule appeared two years ago. The ectopic breast containing the mass was excised with axillary dissection. It was an invasive ductal carcinoma and metastasis was detected in one lymph node. She received local radiotherapy after 6 cycles of chemotherapy and has now been taking hormonotherapy. Ectopic breast tissue has potential for malignant transformation. As its carcinoma has a worse prognosis and a higher incidence of metastasis because of delayed diagnosis, prophylactic excision may be recommended.

Extended lymphadenectomy for gastric cancer: a single center experience in Istanbul.

BACKGROUND/AIMS: Surgery is the only potentially curative treatment for gastric carcinoma. Western surgeons have recently performed extended operations while Japanese surgeons reported therapeutic value of extended lymphadenectomy (D2, D3) long before. We aimed to observe the benefits and hazards of this procedure. METHODOLOGY: We analyzed respectively 56 patients operated for gastric cancer between 2001 and 2004. RESULTS: Thirty-five patients were male and median age was 63 years (range, 34-85 years). Subtotal and total gastrectomies were performed in 29 and 27 patients, respectively. Tumor extension and patient's physical status determined the extent of node dissection. Disease stage was III or IV in 63.2% of patients. Number of maximal nodes resected was 48 and maximal metastatic node count was 41. Splenectomy was performed in 4 (14%). Roux en Y anastomosis was performed either manually or with a circular stapler. Four patients (7.1%) had postoperative complications with no hospital mortality. CONCLUSIONS: Gastric resection with extended lymph node dissection is a safe procedure with acceptable morbidity when performed by an experienced surgeon.

A rare case of duodenal duplication treated surgically.

Duodenal duplication, a rare congenital malformation, can also be observed in adulthood. Although it can be cystic or tubular, communicating or non-communicating, cystic and non-communicating forms are the most common. Several complications, such as obstruction, bleeding, perforation and pancreatitis, may result. Optimal treatment is total excision, although endoscopic procedures have also been described in appropriate cases. If total excision is not possible, subtotal excision and internal derivation can be performed. The 38-year-old woman presented here had occasional attacks of abdominal pain and obstruction, and we considered the diagnosis of duodenal duplication by abdominal computerized tomography. As we confirmed the diagnosis with operative findings and histopathological signs, we treated her with subtotal excision and intraduodenal cystoduodenostomy.

Diagnostic value of plasminogen activity level in acute mesenteric ischemia.

AIM: To investigate the changes in plasminogen activity level during mesenteric ischemia. METHODS: We performed laparotomy in 90 female Wistar-Albino rats (average weight 230 g). In sham groups (SL) (Groups I and II) the superior mesenteric artery (SMA) and vein (SMV) were explored, but not tied. In SMA groups (Groups III and IV) the SMA was ligated, and in SMV groups (Groups V and VI) the SMV was ligated. On re-laparatomy 2 mL of blood was drawn at 1 h in groups I, III and V, and at 3 h in groups II, IV and VI. Plasminogen levels were assessed and comparisons were made between groups and within each group. RESULTS: The mean plasminogen activity in the SL group was significantly higher than SMA (25.1 +/- 10.8 vs 11.8 +/- 4.6, P < 0.001) or SMV (25.1 +/- 10.8 vs 13.7 +/- 4.4, P < 0.001) groups both at 1 h and at 3 h (29.8 +/- 8.9 vs 15.1 +/- 5.7, P < 0.0001; 29.8 +/- 8.9 vs 14.2 +/- 2.9, P < 0.0001). There were no significant differences between the values of SMA and SMV groups at 1 h (P = 0.28) and at 3 h (P = 0.71). In each group, plasminogen activity levels did not change significantly between the two measurements performed at 1 h and 3 h. CONCLUSION: We conclude that blood plasminogen activities decrease during early phases of both arterial and venous mesenteric ischemia which may be a useful marker for early diagnosis.