Primer consenso español sobre el uso de la radioterapia intraoperatoria en el cáncer de mama. Conclusiones del panel de expertos / First Spanish consensus on the use of intraoperative radiotherapy in breast cancer. Conclusions of the expert panel

Introducción: la publicación de ensayos aleatorizados con resultados a largo plazo ha demostrado que la radioterapia intraoperatoria (RIO) en cáncer de mama en estadio precoz puede ser una alternativa terapéutica en casos bien seleccionados. En el presente trabajo se presentan los resultados del Primer Consenso de Radioterapia Intraoperatoria en Cáncer de Mama realizado de manera multidisciplinar en España. Material y método: se hizo una revisión sistemática de la literatura y se invitó a todos los oncólogos radioterápicos y cirujanos expertos en RIO en cáncer de mama de España a participar en el consenso. Se aplico la siguiente metodología en 2 fases: a) la creación de un grupo de trabajo y la revisión de la evidencia; b) la realización de la encuesta y generación de recomendaciones consensuadas. Resultados: han participado un total 95,65% de los centros que actualmente utilizan esta técnica en cáncer de mama y que fueron invitados. Los expertos estuvieron de acuerdo en el uso de RIO exclusiva en cáncer de mama en aquellas pacientes mayores de 60 años y por encima de 50 años posmenopáusicas, con carcinoma ductal infiltrante o subtipos histológicos favorables, sin invasión linfovascular, tumores menores o iguales a 25 mm, márgenes de resección libres y receptores hormonales positivos. La utilización de RIO como rescate de recidiva local después de la irradiación externa alcanzó un nivel de consenso muy fuerte. Conclusión: el presente consenso pretende establecer las guías respecto a las indicaciones de RIO exclusiva o como sobreimpresión anticipada y ser una ayuda para la toma conjunta de decisiones. (AU)

Introduction: The publication of randomized trials with long-term results has demonstrated that intraoperative radiation therapy (IORT) in early-stage breast cancer can be a therapeutic alternative for well-selected cases. This paper present work presents the results of the first multidisciplinary consensus on IORT in breast cancer carried out in Spain. Materials and methods: A systematic literature review was conducted, and all radiation oncologists and surgeons with expertise in IORT for breast cancer in Spain were invited to participate in the consensus. The following methodology was employed in two phases: a) creation of a working group and review of the evidence; b) conduct of the survey and generation of consensus recommendations. Results: A total of 95.65% of the invited centers currently utilizing this technique in breast cancer participated. The experts agreed on the use of exclusive intraoperative radiation therapy in breast cancer for patients above 60 years of age and above 50 years postmenopausal, with invasive ductal carcinoma or favorable histological subtypes, no lymphovascular invasion, tumors less than or equal to 25 mm, clear surgical margins, and positive hormone receptor. The use of IORT as salvage surgery for local recurrence after external irradiation achieved a very strong consensus level. Conclusion: The present consensus aims to establish guidelines regarding the indications for exclusive IORT or as an early boost, and to serve as an aid for joint decision-making. (AU)

Is Axillary Assessment of Ductal Carcinoma In Situ of the Breast Necessary in All Cases?

BACKGROUND: Staging of the axilla in women with ductal carcinoma in situ (DCIS) is a point of controversy. We aimed to assess whether there is a group of patients in whom axillary assessment can be avoided and whether the likelihood of underdiagnosis of infiltrating carcinoma is sufficient to justify this evaluation. MATERIALS AND METHODS: This was a multicenter, prospective, observational study of patients who were operated on between 2008 and 2018 in three Spanish hospitals, with a diagnosis by radiological or excisional biopsy of DCIS and clinically and radiologically negative axilla. RESULTS: A total of 530 patients with a preoperative diagnosis of DCIS were studied. An axillary assessment was performed in 77% of the patients. In 397 patients, selective sentinel lymph node biopsy was performed. Axillary involvement was found in 7.2% of all patients, which dropped to 2.15% if we only included DCIS diagnosed after a definitive anatomical pathology analysis. Underdiagnosis was correlated with the type of biopsy performed: the risk was 1.34 times as high if the biopsy was performed with a core needle. The risk of lymph node metastasis was higher when there was lymphovascular invasion and when mastectomy was performed. CONCLUSIONS: We propose an axilla management algorithm in patients with a preoperative diagnosis of DCIS. The patients who would benefit from sentinel lymph node biopsy would be those who are not candidates for breast-conserving surgery, those with a BIRADS 5 lesion biopsied by core-needle biopsy, and those whose definitive diagnosis is lymphovascular invasion.

Immunosuppressive profiles in liquid biopsy at diagnosis predict response to neoadjuvant chemotherapy in triple-negative breast cancer.

BACKGROUND: Triple-negative breast cancer (TNBC) is characterised by high pathological complete response to neoadjuvant chemotherapy (NAC). However, refractory and poor NAC responders still face very poor outcome, emphasising the urgent need for tools that facilitate identification of these patients, so that surgery or alternatives to NAC are considered early in the treatment protocol. MATERIALS AND METHODS: We combined metabolomics, exosome circulating miRNAs and flow cytometry experimental approaches in TNBC patients at diagnosis with immunohistochemistry in needle biopsy tumours to generate NAC-response predictive models. We also co-cultured and studied crosstalk between isolated patient-derived early myeloid-derived suppressor cells (eMDSCs) and TNBC cancer cell lines. RESULTS: Blood-derived liquid biopsy biomarkers display a novel immunosuppressive profile of tryptophan-derived metabolites and eMDSC levels that significantly predict NAC response. Notably, indoleamine 2,3-dioxygenase 1 (IDO1) expression in tumour cells inversely correlated with circulating tryptophan levels but directly correlated with the level of eMDSCs. In addition, a set of circulating exosome miRNAs that target pathways of immune maturation also predicted poor NAC response prior to chemotherapy. Interestingly, expression of IDO1 increased when TNBC cell lines were co-cultured with patient-derived eMDSCs and this, in turn, promoted proliferation of eMDSCs. CONCLUSION: Our findings demonstrate that the suppressive pathways of the immune system play a key role in modulating the NAC response in TNBC. We identify a crosstalk mechanism between tumour cells and eMDSCs that exacerbates immunosuppression. These results provide a potential new tool to identify poor NAC responders for alternative strategies of treatment, including early surgical resection of the tumour, and to explore in them alternative immune therapies.

Recidiva local del cáncer de mama tras reconstrucción con injerto autólogo / Local recurrence of breast cancer after autologous graft reconstruction

Las recurrencias ipsilaterales de cáncer de mama tras realización de cirugía radical y reconstrucción posterior, son poco frecuentes. El propósito de este estudio es examinar su incidencia y los factores asociados en las pacientes sometidas a mastectomía y reconstrucción con colgajo autólogo por carcinoma invasivo, tras revisar nuestra serie de pacientes mastectomizadas por cáncer de mama con reconstrucción con colgajo autólogo en los últimos 10 años (AU9

Ipsilateral recurrence of breast cancer after radical surgery and subsequent reconstruction is rare. The aim of this study was to analyse its incidence and associated factors in patients undergoing mastectomy and autologous graft reconstruction for invasive carcinoma, after analysing our series of patients undergoing these procedures in the last 10 years (AU)

Breast dermatofibrosarcoma. Case report / Dermatofibrosarcoma protuberans de mama: a propósito de un caso

No disponible

Evisceración vaginal. Abordaje abdominal y reparación con malla sintética / Vaginal evisceration. Abdominal approach and synthetic mesh repair

La evisceración vaginal espontánea es un fenómeno raro en la práctica clínica diaria. Se han publicado más de 70 casos hasta la actualidad desde que McGregor comunicara el primer caso a comienzos del siglo pasado. La situación ocurre generalmente en pacientes posmenopáusicas con hipoestrogenismo asociado a cirugía ginecológica previa. Recientemente, se ha descrito también en situaciones no ginecológicas tras una proctectomía perineal. Presentamos un nuevo caso de evisceración vaginal espontánea en una mujer posmenopáusica con cirugía ginecológica previa. La reparación se efectuó con malla a través de una laparotomía convencional (AU)

Spontaneous vaginal evisceration is a rare phenomenon in daily clinical practice. Since McGregor reported the first case at the beginning of the past century, more than 70 cases have been reported to date. Spontaneous vaginal evisceration usually occurs in patients with postmenopausal hypoestrogenism associated with previous gynecologic surgery. This entity has recently been described in non-gynecological conditions after perineal proctectomy. We present a new case of spontaneous vaginal evisceration in a postmenopausal woman with previous gynecological surgery. Surgical mesh repair was performed through conventional laparotomy (AU)

Utilidad de la colangiografía por resonancia magnética previa a la colecistectomía en la pancreatitis aguda biliar / Utility of magnetic resonance cholangiography prior to cholecystectomy in acute biliary pancreatitis

Objetivo. Análisis del papel de la colangiografía por resonancia magnética (C-RM) en pacientes candidatos a colecistectomía profiláctica tras pancreatitis aguda (PA) biliar. Material y método. Estudio prospectivo de pacientes con PA moderada (criterios de Atlanta), ingresados en nuestro hospital entre enero 2004 y marzo 2005. Se diagnosticó PA biliar mediante clínica compatible, elevación de amilasa sérica mayor al triple del límite superior y ecografía de colelitiasis. Se practicó C-RM en todos los pacientes incluidos. El diagnóstico por C-RM de litiasis de vía biliar (LVB) fue seguido de colangiopancreatografía retrógrada endoscópica (CPRE) y esfinterotomía endoscópica (EE), y luego colecistectomía laparoscópica (CL). A la C-RM negativa siguió directamente una CL. No se realizó colangiografía intraoperatoria de forma sistemática. Resultados. De 31 pacientes ingresados se incluyó a 27 (edad media, 66,4 ± 18 años; un 78% mujeres). Cuatro pacientes fueron excluidos: 2 rechazaron colecistectomía y 2 por PA grave. El intervalo de espera media entre pancreatitis y colecistectomía fue de 1,7 ± 1,2 meses. Tres pacientes (11,1%) sufrieron recurrencia, todos en las primeras 4 semanas. Cuatro pacientes (14,8%) presentaron LVB en C-RM. La CPRE con EE extrajo la totalidad de cálculos en 3. En 1 caso se extrajeron 12 cálculos de vía biliar, pero fue imposible la litiasis en el conducto cístico. Hubo 1 caso de LVB precolecistectomía que presentó re-currencia a las 4 semanas de la colecistectomía. Otro paciente con C-RM negativa también sufrió una PA poscolecistectomía. Veinticinco de 27 pacientes (93%) han permanecido asintomáticos (mediana, 16 meses; rango, 8-22 meses). Conclusiones. La C-RM en pacientes con PA biliar previamente a la CL no debe practicarse de manera sistemática. Es un método adecuado para pacientes seleccionados con esta patología (AU)

Aim. To analyze the role of magnetic resonance cholangiography (MRC) in candidates for cholecystectomy after acute biliary pancreatitis (ABP). Methods. We performed a prospective study of patients with mild ABP (Atlanta criteria) admitted to our hospital from January 2004 to March 2005. Diagnosis of ABP was based on clinical features, serum amylase levels more than 3 times higher than the upper level of normality, and gallstones detected by ultrasonography. In all patients, MRC was performed preoperatively. If positive for common bile duct stones (CBDS), endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) was performed, followed by laparoscopic cholecystectomy (LC). When MRC was negative, LC was performed directly. Intraoperative cholangiography was not routinely performed . Results. Of the 31 patients admitted, 27 were included (mean age 66.4 ± 18 years, 78% female). Four patients were excluded: 2 refused to undergo cholecystectomy and two had severe ABP. The mean interval between onset of ABP and cholecystectomy was 1.7 months ± 1.2. Three patients (11.1%) experienced recurrence within 4 weeks of the index admission. MRC revealed CBDS in four patients (14.8%). In 3 patients, all the gallstones were removed by ERCP and ES. In one patient, 12 gallstones were retrieved but attempts to remove a stone from the cystic duct were unsuccessful. One patient with preoperative CBDS was readmitted 4 weeks after cholecystectomy due to recurrence. Another patient with negative findings on preoperative MRC was also readmitted with postcholecystectomy ABP. Twenty-five of the 27 patients (93%) have remained asymptomatic after cholecystectomy (median follow-up: 16 months [8-22 months]). Conclusions. MRC should not be routinely used in the preoperative evaluation of patients with ABP but is an accurate tool in selected patients with this disease (AU)

[Utility of magnetic resonance cholangiography prior to cholecystectomy in acute biliary pancreatitis]. / Utilidad de la colangiografía por resonancia magnética previa a la colecistectomía en la pancreatitis aguda biliar.

AIM: To analyze the role of magnetic resonance cholangiography (MRC) in candidates for cholecystectomy after acute biliary pancreatitis (ABP). METHODS: We performed a prospective study of patients with mild ABP (Atlanta criteria) admitted to our hospital from January 2004 to March 2005. Diagnosis of ABP was based on clinical features, serum amylase levels more than 3 times higher than the upper level of normality, and gallstones detected by ultrasonography. In all patients, MRC was performed preoperatively. If positive for common bile duct stones (CBDS), endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) was performed, followed by laparoscopic cholecystectomy (LC). When MRC was negative, LC was performed directly. Intraoperative cholangiography was not routinely performed . RESULTS: Of the 31 patients admitted, 27 were included (mean age 66.4 +/- 18 years, 78% female). Four patients were excluded: 2 refused to undergo cholecystectomy and two had severe ABP. The mean interval between onset of ABP and cholecystectomy was 1.7 months +/- 1.2. Three patients (11.1%) experienced recurrence within 4 weeks of the index admission. MRC revealed CBDS in four patients (14.8%). In 3 patients, all the gallstones were removed by ERCP and ES. In one patient, 12 gallstones were retrieved but attempts to remove a stone from the cystic duct were unsuccessful. One patient with preoperative CBDS was readmitted 4 weeks after cholecystectomy due to recurrence. Another patient with negative findings on preoperative MRC was also readmitted with postcholecystectomy ABP. Twenty-five of the 27 patients (93%) have remained asymptomatic after cholecystectomy (median follow-up: 16 months [8-22 months]). CONCLUSIONS: MRC should not be routinely used in the preoperative evaluation of patients with ABP but is an accurate tool in selected patients with this disease.

Depresión y estado tiroideo en pacientes mayores de 60 años / Depression and thyroid condition in patients older than 60 years

Se estudiaron 26 pacientes con una edad media de 63,8 ñ 8,4 años, seleccionados aleatoreamente de un área de salud, con el objetivo de conocer la relación entre la frecuencia de síntomas depresivos y el perfeccionamiento del eje hipotálamo-hipófiso-tiroideo en personas de la tercera edad. A cada sujeto se le determinó la concentración de toxina total (T4t) y de triidotironina total (T3t) en plasma por radioinmunoensayo. Cada uno fue entrevistado de forma individual y se evaluó mediante las escalas de Beck y de Heimler para conocer la frecuencia de síntomas depresivos y la percepción de su funcionamiento social, respectivamente. Los resultados muestran que una ecuación de regresión múltiple en la que la frecuencia de síntomas depresivos es la variable dependiente y que ajusta con una R múltiple de 0,85 para p=2,04 x 10-7 con los coeficientes de -0,03 y de 0,31 para la T4t y el funcionamiento social negativo, respectivamente. Se discute el papel de las hormonas tiroideas en la depresión de los ancianos como moduladores de las catecolaminas en el sistema nervioso central y se analiza la acción sinérgica de los factores hormonales y sociales en el estado de ánimo de estos sujetos

Depresión y estado tiroideo en pacientes mayores de 60 años / Depression and thyroid condition in patients older than 60 years

Se estudiaron 26 pacientes con una edad media de 63,8 ñ 8,4 años, seleccionados aleatoreamente de un área de salud, con el objetivo de conocer la relación entre la frecuencia de síntomas depresivos y el perfeccionamiento del eje hipotálamo-hipófiso-tiroideo en personas de la tercera edad. A cada sujeto se le determinó la concentración de toxina total (T4t) y de triidotironina total (T3t) en plasma por radioinmunoensayo. Cada uno fue entrevistado de forma individual y se evaluó mediante las escalas de Beck y de Heimler para conocer la frecuencia de síntomas depresivos y la percepción de su funcionamiento social, respectivamente. Los resultados muestran que una ecuación de regresión múltiple en la que la frecuencia de síntomas depresivos es la variable dependiente y que ajusta con una R múltiple de 0,85 para p=2,04 x 10-7 con los coeficientes de -0,03 y de 0,31 para la T4t y el funcionamiento social negativo, respectivamente. Se discute el papel de las hormonas tiroideas en la depresión de los ancianos como moduladores de las catecolaminas en el sistema nervioso central y se analiza la acción sinérgica de los factores hormonales y sociales en el estado de ánimo de estos sujetos