Anna Fachinetti

Hyperinsulinemia, family history of hypertension, and essential hypertension

The aim of this study was the evaluation of the relationships among hyperinsulinemia, a family history of hypertension, and essential hypertension. Insulin and C-peptide responses to an oral glucose load were studied in 175 lean normotensives (N) and untreated hypertensives (H) with (F+) and without (F-) a family history of hypertension: 30 NF-, 30 NF+, 45 HF-, and 70 HF+. The groups were comparable for age, sex, body mass index, and blood pressure. The following parameters were evaluated: plasma glucose (G), serum insulin (I), and C-peptide (Cp) before and 30, 60, 90, and 120 min after the glucose load, fasting glucose/insulin ratio (ISI), fasting insulin/C-peptide ratio (I/Cp), and 24-h ambulatory blood pressure monitoring. Plasma glucose was measured, fasting and during the test, and it and I/Cp were similar in the four groups. Serum insulin and Cp, both fasting and stimulated, were significantly higher and ISI lower in normotensives and hypertensives with hypertensive parents. Grouping the subjects first on the basis of blood pressure and then on the basis of family history, no differences were found between normotensives and hypertensives, whereas I and Cp, fasting and stimulated, were significantly higher and ISI lower in subjects with positive as compared to negative family history. The closest correlations between insulin and ambulatory blood pressure were found in normotensive with hypertensive parents; in hypertensives with hypertensive parents we only found a direct correlation between fasting Cp and nocturnal blood pressure fall; in hypertensives with normotensive parents insulin inversely correlated with nocturnal blood pressure fall. Insulin resistance seems to have a familial basis, independently of the presence of hypertension. Instead of showing a causal relationship between insulin resistance and hypertension, our results indicate that the two are partly independent components of a common familial pattern.

Insulin and Diastolic Dysfunction in Lean and Obese Hypertensives: Genetic Influence

We investigated the influence of genetic predisposition to hypertension by studying the relation between insulin sensitivity and left ventricular (LV) mass and function in untreated lean and obese hypertensives. We selected 50 lean hypertensives with normotensive parents (negative family history of hypertension [F-]), 64 lean hypertensives with 1 or both parents hypertensive (positive family history of hypertension [F+]), 40 obese F- hypertensives, and 43 obese F+ hypertensives. The 4 groups were comparable regarding age, gender, 24-hour blood pressure profile, and known duration of hypertension. We measured glucose, insulin, and C-peptide during fasting and during an oral glucose tolerance test; LV morphology and function were assessed by digitized M-mode echocardiography. Glucose (fasting and test) levels were normal in all and similar among the 4 groups. Insulin and C-peptide (fasting and stimulated) levels were higher in obese hypertensives than in lean hypertensives; at similar body mass index, insulin and C-peptide levels were higher in F+ than in F- groups. Compared with lean hypertensives, obese hypertensives had greater LV mass index; LV systolic function was normal in all and similar among the groups. The indices of LV diastolic function were significantly lower in F+ than in F- groups. LV mass index did not correlate with metabolic parameters; the indices of LV diastolic function were inversely correlated with insulin area during test in only the 2 F+ groups. In conclusion, genetic predisposition to hypertension is associated with a reduced insulin sensitivity and affects the response of the myocardium to increased insulin levels, inducing a greater impairment of diastolic function. Insulin sensitivity and genetic predisposition to hypertension seem to have no influence on LV mass.

Management of breast cancer during pregnancy

INTRODUCTION Pregnancy-associated breast cancer (PABC) is one of the most common malignancies during pregnancy. Since maternal age at the time of pregnancy is increasing, PABC rate is expected to increase. Diagnostic delays are common. METHODS Retrospective observational study analysing twelve pregnant patients with breast cancer who underwent surgical treatment during the period of February 2006 to June 2013 at the Department of Surgery I, University of Insubria Varese. RESULTS The median age of pregnant patients was 34 y (range 28-44 y). Three patients were affected by BRCA1 mutation. In six patients diagnosis was made during gestation, in the other six patients breast cancer was discovered during breastfeeding. Ten patients underwent breast-conserving surgery. Sentinel lymph node biopsy was performed in six patients; in one of them it was positive so axillary dissection was simultaneuosly performed. Six patients underwent axillary dissection ab initio. In all cases the histological type was invasive ductal carcinoma; grade 3 in ten patients and grade 2 in two patients. Eleven of twelve patients received adjuvant chemotherapy, one patient both adjuvant and neoadjuvant. In three cases also radiation therapy was performed after delivery. In all cases healthy babies were born. Nine of twelve patients are still alive and disease free, after a median follow-up of 20 months (range 3-52 months). Three patients died from systemic progression of the disease. CONCLUSION There are no significant series of patients in worldwide literature to develop standard protocols. Pregnant women must be followed by a multidisciplinary team.

Neuroendocrine breast cancer: retrospective analysis of 96 patients and review of literature

BACKGROUND AND PURPOSE Primary neuroendocrine breast carcinomas (NEBC) are uncommon lesions; they constitute approximately 1% of all breast cancers and mostly affect elderly patients. According to the most recent World Health Organization classification, it concerns almost exclusively the female population between the sixth and seventh decades. The aim of this retrospective study is to analyze the clinicopathological aspects of 96 NEBC patients who had undergone surgical resection at a single institute. METHODS We retrospectively analyzed a series of 96 patients who underwent surgical resection for NEBC between January 1992 and August 2013. RESULTS The 96 patients with NEBC were divided into two categories: 61 (63.5%) in whom the expression of a neuroendocrine marker was present in more than 50% of neoplastic cells and 35 (36.5%) with a minor neuroendocrine component. Our data show a mean age of the patients at diagnosis of 70 years (range 42-87 years); the 10-year survival of the 96 patients was 87%, moreover we report tumor location, type of surgical operation, tumor size (average 2.1 cm), hormone therapy, chemotherapy and radiotherapy if used, recurrence sites, overall and disease free survival times. CONCLUSIONS This study showed a better prognosis in patients with NEBC compared with breast carcinomas with a minor neuroendocrine component and with conventional invasive ductal or lobular cancers.

Predictors of loco-regional recurrence and cancer-related death after breast cancer surgery.

Abstract:  To determine which tumor‐related factors might predispose the patient to loco‐regional recurrence or death and the impact of these factors on the different types of events. We retrospectively analyzed the data of 1991 women between January 1998 and March 2010 for a first primary nonmetastatic breast cancer and treated with surgery and neo‐adjuvant/adjuvant therapy. The overall survival distribution was estimated using the Kaplan–Meier method. The prognostic impact of several factors on cumulative overall and loco‐regional recurrence free survival was evaluated by univariate (log‐rank test) and multivariate analysis (Cox regression). At log‐rank test, pT, nodal status, histotype, grading, lymphangioinvasive growth, tumor diameter, estrogen receptors (ER) status, progesterone receptors (PR) status, expression of Ki67, and expression of Her2/neu had a prognostic value on loco‐regional recurrence or overall survival. In the multivariate analysis grading remained the only independent predictor of loco‐regional recurrences. With regard to overall survival, the Cox model selected grading along with nodal status and PR status. Loco‐regional recurrences after breast cancer surgery are not frequent events. They are markers of tumor aggressiveness and predictor of an increased likelihood of cancer‐related death. However, loco‐regional recurrence and systemic tumor progression are partially independent events, since some prognostic factors differ.

Surgical margins in breast conservation

Breast cancer is the most common tumor affecting women worldwide. Breast-conserving therapy (BCT) followed by irradiation nowadays is the treatment of choice for early-stage disease; there is no difference in long-term survival between mastectomy and BCT combined with external radiotherapy. A positive margin is associated with increased risk of local recurrences after BCT for invasive breast cancer and ductal carcinoma in situ. The exact definition of an adequate surgical margin after breast cancer resection has long been debated among physicians and represents an area of considerable variation in clinical practice. There is a lack of standardization in the pathology methods of margin evaluation, which yields little consensus regarding what constitutes an adequate negative margin. As a consequence, patient management varies widely based on the threshold that surgeons accept for adequate margins and the subsequent need for re-excision. We analyze and discuss recent literature about this topic both from the pathological and from the surgical point of view.

Prognostic role of micrometastases in sentinel lymph node in patients with invasive breast cancer

BACKGROUND AND PURPOSE OF THE STUDY Axillary lymph node status at the time of diagnosis remains one of the most important prognostic factors in women with breast cancer. Sentinel lymph node biopsy (SLNB) proved to be a reliable method for the evaluation of axillary nodal status in early-stage invasive breast cancer. The prognostic value and potential therapeutic consequences of SLN micrometastases remains a matter of great debate. PATIENTS AND METHODS From January 1998 to March 2011, 1,976 consecutive patients with non-metastatic invasive breast cancer underwent surgical treatment; 1,080 of them (54.6%) underwent SLNB. We collected data regarding demography, preoperative lymphoscintigraphy, type of surgery, histopathologic and immunohistochemical features and adjuvant treatment. MAIN FINDINGS A mean number of 2.1 ± 1.4 (range 1-13) SLN per patient were collected, a total of 2,294 nodes. SLNs were macrometastatic in 16.7% of patients and micrometastatic in 3.3%. Among the patients with positive SLN 93.6% underwent complete ALND. The overall survival (OS) and disease-free survival (DFS) of 72 patients with micrometastases in SLN at 60 months was 100%, similar to patients with negative SLN (98.7%), quite different from the DFS of N1-N3 patients (85.8%). Statistically significant differences in OS and DFS were observed between patients with N1mi and the group with N1-N3 sentinel node (p < 0.001 and p = 0.04) and also between patients with negative SLN and those with macrometastatic SLN (p < 0.001 for both). CONCLUSION SLN micrometastases could represents an epiphenomenon of peritumoral lymphovascular invasion which impacts independently on the survival of patients with invasive breast cancer.

Wound healing and postsurgical complications in breast cancer surgery: a comparison between PEAK PlasmaBlade and conventional electrosurgery – a preliminary report of a case series

Purpose PEAK PlasmaBlade is a recent and distinctive type of electrosurgical device. Previous studies have already documented some meaningful advantages of this device over conventional electrosurgery. This study compared the use of PEAK PlasmaBlade to standard electrosurgery in mastectomy and breast conservative surgery. The purpose was to test the impact of PEAK PlasmaBlade on the wound-healing process and on postsurgical complications in breast cancer surgery. Methods Sixty patients undergoing breast cancer surgery were enrolled. The PEAK PlasmaBlade was used for 20 of those. A standard electrosurgical device was used for the other 40 patients. The 2 groups were homogenous in age, body mass index, comorbidities and type of surgery. We recorded wound complications, serum drainage amount and duration of stay, blood loss, time of surgery, length of hospital stay, and total number of medications required. Results The 2 groups were not significantly different in terms of patient characteristics. A statistically significant reduction in incidence of seroma was observed in the PEAK group: only 10% versus 37.5% of the patients in the conventional electrosurgery group developed this complication (Fisher exact test, P = 0.034). Conclusion Seroma is the most important wound complication in breast surgery. The research of new instruments that might reduce its incidence is desirable. In order to validate or deny the results of this study, it is necessary to enroll more subjects and to consider the impact of this device on axillary lymph node dissection.

Metachronous bilateral ectopic breast carcinoma: a case report

An incomplete regression of the mammary line during embryogenesis occurs in 0.2-6% of the population, which may result in the presence of ectopic breast tissue (EBT). The development of a carcinoma in the EBT is a rare event. The authors present a case report of a 76-year-old female patient, with a lobular carcinoma in an abdominal wall EBT submitted to surgery and adjuvant chemotherapy.