Breast cancer and its impact in male transsexuals.

INTRODUCTION: Lesbian, gay, and bisexuals have unique healthcare needs. Breast cancer is leading cancer in women, worldwide, accounting for 25% of all cases. Annual incidence rates increased significantly in all countries and age groups. The occurrence of breast cancer is rare in transgender population. As they have very limited access to medical care, it is much less likely to pursue breast cancer screening than in other individuals not identified as transgender. REVIEW OF THE CASES FROM LITERATURE: Up to date, only 13 cases of the breast cancer transsexuals (female to male) have been reported in six published papers worldwide. Histological examination of the breast tumor in female-to-male transgender showed progesterone/estrogen-positive invasive ductal carcinoma. DISCUSSION: Gender identity describes a person's inherent sense of being a woman, man, or of neither gender, whereas sexual orientation refers to how people identify their physical and emotional attraction to others. Gender reassignment surgery, as series of complex surgical genital and non-genital procedures, is recognized as the most effective treatment for patients with gender dysphoria. The two main principles of hormone therapy for transgender patients are to reduce endogenous hormone levels and their associated sex characteristics and replace them with hormones of the preferred sex. Breast cancer infrequently occurs in transgender patients. Even breast core biopsies can be difficult for interpreting after changes in breast tissue in female-to-male transsexuals following gender reassignment. CONCLUSION: Reviewing the literature, so many different data concerning probability of breast cancer in sexual minority can be found. Breast cancer screening program should be offered to all transgender individuals according to national guidelines. Very important is to take into consideration a transgender person's natal and surgical anatomy, unique clinical concerns for depression and anxiety, risk of suicide together with risk factors including experiences of harassment or physical or sexual violence, low education level, and unemployment. Understanding the need for mammography in these often marginalized groups is very important in addressing breast cancer disparities despite differences in insurance coverage in some countries and greater concern for the cancer of the breast in residual breast tissue. The best screening rule, ever, for breast cancer in male transsexuals and other similar population should be, besides surgical history and hormonal status, "Screen Now, Screen Regularly and Screen What You Have."

Intraoperative ultrasound in breast cancer surgery-from localization of non-palpable tumors to objectively measurable excision.

BACKGROUND: The utilization of intraoperative ultrasound (IOUS) in breast cancer surgery is a relatively new concept in surgical oncology. Over the last few decades, the field of breast cancer surgery has been striving for a more rational approach, directing its efforts towards removing the tumor entirely yet sparing tissue and structures not infiltrated by tumor cells. Further progress in objectivity and optimization of breast cancer excision is possible if we make the tumor and surrounding tissue visible and measurable in real time, during the course of the operation; IOUS seems to be the optimal solution to this complex requirement. IOUS was introduced into clinical practice as a device for visualization of non-palpable tumors, and compared to wire-guided localization (WGL), IOUS was always at least a viable, or much better alternative, in terms of both precision in identification and resection and for patients' and surgeons' comfort. In recent years, intraoperative ultrasound has been used in the surgery of palpable tumors to optimize resection procedures and overcome the disadvantages of classic palpation guided surgery. OBJECTIVE: The aim of this review is to show the role of IOUS in contemporary breast cancer surgery and its changes over time. METHODS: A PubMed database comprehensive search was conducted to identify all relevant articles according to assigned key words. CONCLUSION: Over time, the use of IOUS has been transformed from being the means of localizing non-palpable lesions to an instrument yielding a reduced number of positive resection margins, with a smaller volume of healthy breast tissue excided around tumor, by making the excision of the tumor optimal and objectively measurable.

Serbian consensus of neoadjuvant therapy for breast cancer: NeoPULSE.

Even though surgery is the primary treatment of operable breast cancer, it has been known for decades that the administration of postoperative adjuvant or preoperative neoadjuvant therapy is extremely important. Indications for neodjuvant therapy administration have been expanded over the years, and nowadays this kind of treatment represents an inevitable option in early breast cancer treatment. The NeoPULSE project, which gathered a group of experts in the field of breast cancer from five Serbian university centres, was formed with the aim to define optimal breast cancer diagnosis, indications for neoadjuvant therapy, therapeutic combinations in relation to molecular/biological parameters of breast cancer, as well as the treatment after neoadjuvant therapy. During two separate expert meetings involving surgeons, medical oncologists, radiation oncologists, a pathologist, and a "Blueprint" workshop, the project participants answered questions over the indications for neoadjuvant therapy. The first part covered local practice and referred to the existence and work of a multidisciplinary team, as well as commonly applied therapeutic regimens in the neoadjuvant setting. Experts analysed personal views regarding indications for the administration and benefits of neoadjuvant therapy, their perception on the correlation between achieving a pathological complete response (pCR) and the outcome of treatment, as well as the attitude towards controversies about this type of treatment, primarily regarding a possible change in the receptor status after therapy and therapeutic options after a suboptimal response. The analysis of the answers pointed to problems and deviations from recommendations in everyday clinical practice, based on which appropriate solutions were proposed. The establishment of such a panel and consensus is an attempt to modernize multidisciplinary teams in Serbia, achieve reaching uniform decisions of all subjects dealing with breast cancer, and therefore, at least in one segment, improve breast cancer treatment in Serbia.

Optimization of breast cancer excision by intraoperative ultrasound and marking needle - technique description and feasibility.

BACKGROUND: We present a surgical technique and the preliminary results of breast cancer excision after insertion of a specially constructed marking needle into the tumor, controlled by intraoperative ultrasound. Resection margins were projected in six directions by ultrasound measurements, determined in relation to the needle, and resection was done in accordance with those measurements. The main objective was to obtain resection margins similar (equal) to those projected by intraoperative ultrasound (10 mm). METHODS: Detailed description of the technique is given. Thirty-two female patients undergoing breast-conserving surgery, up to 30 mm in diameter, for palpable and non-palpable invasive breast cancer, were operated on using this technique. Its feasibility was tested by analyzing the success (rate) of needle placement in the tumor, the measurements executed, and the performance of the excision. RESULTS: All stages of the technique were successfully performed to completion on all 32 patients. The procedure of needle placement and ultrasound measurement of distances took 11 min on average (between 6 and 20 min). The average distance of the tumor margin from the resection margin was 12.9 mm (2 to 30 mm, 95% confidence interval [11.9, 14.06]). There was one patient with a positive resection margin (3%). CONCLUSIONS: The technique of excising palpable and non-palpable breast cancer by intraoperative ultrasound and an especially constructed marking needle is feasible and comfortable to perform. Preliminary results imply that resection volume can be rationalized, with the same or better oncological safety.

Lymph nodes behind the axillary neurovascular bundle: case report and cadaveric study of frequency and distribution.

Axillary clearance was undertaken in a 58-year-old male with massive lymph node enlargement caused by melanoma from an unknown primary site. We discovered a group of metastatic lymph nodes behind the axillary neurovascular bundle. This group of nodes (retro-axillary lymph nodes) could represent an extension of the subscapular group, or the seventh group of axillary lymphoid nodes. They were successfully removed using an ad hoc surgical technique, and the subsequent findings are presented herein. To check the frequency of these lymph nodes in this area, we conducted a study on 15 cadavers (30 armpits). The technique of cadaveric sampling is described. Retro-axillary tissue was histologically processed to determine the number of lymph nodes present. It was found that lymph nodes were present in the defined area in 18 of the 30 (60 %) armpits explored. We recommend assessment of the retro-axillary space during surgery entailing massive axillary lymph node involvement.

Totally implantable central venous catheters of the port-a-cath type: complications due to its use in the treatment of cancer patients.

PURPOSE: A multidisciplinary approach to the treatment of patients with malignant diseases requires adequate venous access in order to safely administer chemotherapy, blood transfusion and blood products, antibiotics, rehydratation and total parenteral nutrition. The insertion of the central venous catheter (CVC), its use and its maintenance can be accompanied by multiple complications. METHODS: Fifty cancer patients were retrospectively enrolled in this study. The obligatory inclusion criterion was an implanted CVC of the port-a-cath type, inserted for chemotherapy administration. This study included patients who had their catheters inserted in the period from 2001 to 2012. RESULTS: The median patient age was 44 years (range 28- 68). Thirty five patients (70%) were female and 15 (30%) male. The port-a-cath had been used from 1 to 40 months (16.8 ± 9 months on average). Breast cancer was the most frequent malignancy (18 patients, 36%). The overall incidence of reported complications was 38%. The most common complications were infections and thromboembolic events, each with an incidence of 10 %. The malposition and disconnection of the port-a-cath were in second place, each with an incidence of 6%. CONCLUSION: Insertion of the CVC carries the possibility of serious complications (thrombosis, infections, occlusions). However, correct implantation and handling performed by experienced and trained surgical and other medical staff significantly decrease the incidence of these complications. The use of the CVC has greatly improved the quality of life and also decreased the morbidity and mortality of the cancer patients in our study.

Changing the role of pCR in breast cancer treatment - an unjustifiable interpretation of a good prognostic factor as a "factor for a good prognosis".

Pathologic complete response (pCR) after neoadjuvant systemic therapy (NAST) of early breast cancer (EBC) has been recognized as a good prognostic factor in the treatment of breast cancer because of its significant correlation with long-term disease outcome. Based on this correlation, pCR has been accepted by health authorities (FDA, EMA) as a surrogate endpoint in clinical trials for accelerated drug approval. Moreover, in recent years, we have observed a tendency to treat pCR in routine clinical practice as a primary therapeutic target rather than just one of the pieces of information obtained from clinical trials. These trends in routine clinical practice are the result of recommendations in treatment guidelines, such as the ESMO recommendation "…to deliver all planned (neoadjuvant) treatment without unnecessary breaks, i.e. without dividing it into preoperative and postoperative periods, irrespective of the magnitude of tumor response", because "…this will increase the probability of achieving pCR, which is a proven factor for a good prognosis…". We hypothesize that the above recommendations and trends in routine clinical practice are the consequences of misunderstanding regarding the concept of pCR, which has led to a shift in its importance from a prognostic factor to a desired treatment outcome. The origin of this misunderstanding could be a strong subconscious incentive to achieve pCR, as patients who achieved pCR after NAST had a better long-term outcome compared with those who did not. In this paper, we attempt to prove our hypothesis. We performed a comprehensive analysis of the therapeutic effects of NAST and adjuvant systemic therapy (AST) in EBC to determine whether pCR, as a phenomenon that can only be achieved at NAST, improves prognosis per se. We used published papers as a source of data, which had a decisive influence on the formation of the modern attitude towards EBC therapy. We were unable to find any evidence supporting the use of pCR as a desired therapeutic goal because NAST (reinforced by pCR) was never demonstrated to be superior to AST in any context.

Expression of connexin-43 in surgical resections of primary tumor and lymph node metastases of squamous cell carcinoma and adenocarcinoma of the lung: a retrospective study.

Background: Connexins are transmembrane proteins forming gap junctions between the cells, which allow intercellular communication. Significance of gap junctions and connexins in lung carcinoma is not yet understood. The objective of the study was to investigate immunohistochemical expression and the localization of connexin-43 (Cx43) in primary lung carcinoma and its lymphatic metastases. Methods: Surgical specimens of excised tumors from 88 patients (45 men and 43 women, 61.9 ± 7.4 years) with lung carcinoma (52 adenocarcinoma (AC), 36 squamous cell carcinoma (SqCC)) who were operated on at the University Hospital "Bezanijska Kosa" in a five-year period (2012-2016) were used. We conducted immunohistochemical staining for Cx43 and measured the degree of expression (percentage of positive cells and staining intensity) as well as localization of Cx43 in primary tumor and in lymphatic metastases. Results: Immunohistochemical analysis of the primary tumors revealed that SqCC showed significantly higher percentage of tumor cells expressing Cx43 as well as higher staining intensity than AC (p < 0.001). Almost 70% of samples with SqCC showed high Cx43 expression, whereas AC showed no expression in more than 50% of cases. Localization of Cx43 expression was most often cytoplasmic (AC and SqCC) and combined membranous and cytoplasmic (SqCC) with very rare instances of nuclear localization (AC). Almost the same pattern in distribution, intensity, and localization of Cx43 expression was observed in the lymph node metastases; however, almost a third of AC cases changed the pattern of Cx43 expression in the metastasis compared to primary tumor. Conclusion: The results of this study showed that lung carcinomas express Cx43 in more than 65% of cases and that it was aberrantly localized (not membranous localization). We highlighted that SqCC expressed Cx43 more than did AC, both in primary tumor and lymphatic metastases. Further research is needed to establish whether Cx43 could be used as a prognostic biomarker in lung carcinoma.

Intraparenchimal Leiomyoma of the Breast.

The most common location of the leiomyoma is uterus, small bowel and the esophagus, however they can occur in any organ. Intraparenchimal leiomyomas of the breast are very rare and only 30 cases were reported in the literature. These histologically benign tumors, may mimic malignancies and therefore may present a diagnostic challenge. Here, we present two new cases. The first case was a 50-year-old woman presented with a 4 cm firm mass in her right breast with discrete localized skin thickening/retraction. The second case was a 35-year-old woman presented with a painless palpable lump in the lower outer quadrant of her right breast. Physical examination, mammography and ultrasound as well as surgical excision were performed in both cases. According to histologic examination and immunohistochemical analysis, a diagnosis of smooth muscle tumor of the breast was made. These tumors clinically and radiologically mimic other breast lesions.  Neither imaging studies nor palpation allow distinction between benign and malignant tumors.

Posterior breast cancer - mammographic and ultrasonographic features.

BACKGROUND/AIM: Posterior breast cancers are located in the prepectoral region of the breast. Owing to this distinctive anatomical localization, physical examination and mammographic or ultrasonographic evaluation can be difficult. The purpose of the study was to assess possibilities of diagnostic mammography and breast ultrasonography in detection and differentiation of posterior breast cancers. METHODS: The study included 40 women with palpable, histopathological confirmed posterior breast cancer. Mammographic and ultrasonographic features were defined according to Breast Imaging Reporting and Data System (BI-RADS) lexicon. RESULTS: Based on standard two-view mammography 87.5%, of the cases were classified as BI-RADS 4 and 5 categories, while after additional mammographic views all the cases were defined as BI-RADS 4 and 5 categories. Among 96 mammographic descriptors, the most frequent were: spiculated mass (24.0%), architectural distortion (16.7%), clustered micro-calcifications (12.6%) and focal asymmetric density (12.6%). The differentiation of the spiculated mass was significantly associated with the possibility to visualize the lesion at two-view mammography (p = 0.009), without the association with lesion diameter (p = 0.083) or histopathological type (p = 0.055). Mammographic signs of invasive lobular carcinoma were significantly different from other histopathological types (architectural distortion, p = 0.003; focal asymmetric density, p = 0.019; association of four or five subtle signs of malignancy, p = 0.006). All cancers were detectable by ultrasonography. Mass lesions were found in 82.0% of the cases. Among 153 ultrasonographic descriptors, the most frequent were: irregular mass (15.7%), lobulated mass (7.2%), abnormal color Doppler signals (20.3%), posterior acoustic attenuation (18.3%). Ultrasonographic BI-RADS 4 and 5 categories were defined in 72.5% of the cases, without a significant difference among various histopathological types (p = 0.109). CONCLUSION: Standard two-view mammography followed by additional mammographic projections is an effective way to demonstrate the spiculated mass and to classify the prepectoral lesion as category BI-RADS 4 or 5. Additional ultrasonography can overcome the mimicry of invasive lobular breast carcinoma at mammography.

Combined spinal-epidural technique: single-space vs double distant space technique.

BACKGROUND/AIM: Several combined spinal-epidural (CSE) anesthesia techniques have been described. This study was designed to compare the single space ("needle-through-needle") technique (SST) and the double distant space technique (DDS) with regards to the time needed for the procedure, patient discomfort during the procedure and patient's preference technique. METHODS: This prospective, randomized single-blind study included 156 patients undergoing colorectal surgery under general anesthesia and CSE. All neuraxial blocks were performed before general anesthesia induction. DDS group of patients had thoracic epidural catheter placed at T6-7 or T7-8, followed by subarachnoid injection at the L2-3 interspace. The SST group of patients had a single injection using the needle-through-needle technique (Espocan needle) at L2-3. The epidural catheter was used for postoperative analgesia for 72 hours. Body habitus, spinal anatomy and spinal landmarks were assessed preoperatively. The number of epidural and spinal punctures, the feeling that the dura is perforated (dural perforation click) and the time needed to perform CSE were also recorded. Complications during epidural catheter placement and perioperative and postoperative epidural catheter function and patient preference for the anesthetic procedure were recorded. RESULTS: Epidural and subarachnoid spaces were successfully identified in all the patients. Duration of CSE procedure, the number of spinal punctures, dural click feeling and the effects of test dose did not differ between the groups. The patients in both groups (90% of DDS and 87% of SST) would choose CSE as preferred method in the future. The CSE procedure was painful for 16% of DDS vs 20% of SST patients. A significant correlation between time needed for CSE technique performance and body habitus (r = 0.338, p < 0.01), spinal landmarks (r = 0.452, p < 0.001) and anatomy (r = 0.265, p < 0.05) was found in the SST group. There was no correlation between the number of epidural/spinal punctures and epidural bacteriological findings. There was no correlation between the patients' choice of the CSE technique and the number of spinal punctures, duration of CSE procedure and epidural catheter stay. CONCLUSION: The two CSE techniques did not differ with regards to the procedure time and patient's preference. Procedure time correlated with body habitus, spinal landmarks and the anatomy in the SST group.

Allogeneic blood transfusion in patients in Dukes B stage of colorectal cancer.

The aim of this study is to evaluate influence of allogeneic blood transfusion on prognosis in patients in Dukes B stage of colorectal cancer. All patients with colorectal cancer who were admitted at our Department of Surgery between January 2000 and December 2004 were analyzed. One hundred fifty-one patients who fulfilled inclusion criteria were enrolled in further evaluation. B stage according to Dukes classification and curative resection were inclusion criteria. Exclusion criteria were polyposis syndromes, nonpolyposis syndromes, inflammatory bowel disease, autoimmune disease and previous blood transfusion. Patients were divided into two groups: Group 1 received ≤ 3 units of allogeneic blood transfusion and group 2 received >3 units of allogeneic blood transfusion. "Cutoff" value of 3 units of blood was defined according to our results and literature data. Follow-up was 5 year. There was no statistical difference between these groups in local recurrence (χ(2) = 0.009, P > 0.05) and distant metastasis (χ(2) = 0.44, P > 0.05). Also, the Kaplan-Meier survival curves were calculated, and long-rank test did not show a survival difference between these two groups (log rank = 0.075, P > 0.05). Postoperative complications are significantly more frequent in Group 2 (χ(2) = 4.67, P < 0.05). Multivariate logistic regression analysis confirmed that intraoperative blood transfusion more than three units had independent influence on local recurrence. Postoperative transfusion more than 3 units was statistically independent prognostic factor for metastasis and mortality. Overall transfusion less than 3 units of allogeneic blood does not influence the outcome of patients in Dukes B stage of colorectal cancer.

[Multifocal Abrikossoff's granular cell tumour of the oesophagus--case report].

INTRODUCTION: Granular cell tumours, relatively uncommon soft tissue tumours, have been a matter of debate among pathologists regarding histogenesis for a long time. Less common locations are in the aerodigestive tract including the oesophagus. CASE OUTLINE: We have recently treated a rare case, a 37-year-old male, who was admitted due to dysphagia and a painful swallow with occasional pharyngo-nasal regurgitation followed with a mild loss of weight. Standard clinical examination including X-ray chest, ECG and laboratory tests did not show pathological findings. Barium contrast oesophagography demonstrated multiple ovoid defects in the wall of the oesophagus. CT scan of the chest confirmed luminal narrowing owing to the tumour of the upper oesophagus. Upper endoscopy showed unusual multifocal nodular lesions alongside the oesophageal axis covered by smooth mucosa. A primary biopsy specimen taken from the largest nodules confirmed an unusual pathological finding of the granular cell tumour. Subtotal, transpleural oesophagectomy was performed and reconstruction was derived by long colon segment interposition through the posterior mediastinum. The postoperative course was uneventful. The operative specimen consisted of four ovoid tumours alongside the oesophagus (the greatest diameter 0.5-1.8, average 1.25). All verified tumours histologicaly consisted of a spindle-shaped or polygonal cells containing small and large eosinophilic granules and central nuclei. Most tumour cells showed strongly positive immunohistochemical staining for S-100 protein. These tumour cells were partially positive for p-53 and Ki-67. No lymph node metastases were detected histologically. CONCLUSION: Multifocal granular cell tumour of the oesophagus is an unusual finding with low incidence, and rarely caused symptoms. Pathological features and multiplicity of such tumours emphasized malignant predisposition requiring surgical resection of the oesophagus.