Augusto León

Conservative treatment of early breast cancer

At our Institution, the treatment policy for early carcinoma of the breast (T1-2, NO, AJC) is lumpectomy followed by radiotherapy to the breast and peripheral lymphatics. From October 1976 until December 1982, 171 patients have been admitted and treated. Radiotherapy was administered with 60 Co, 5.000 cGy in 5 weeks to the breast and lymphatics plus a boost to the scar giving q.s.p. 6.400 cGy at maximum tumor depth. With a minimum follow-up of 3 years and a median follow-up of 61.7 months the locoregional control was 94.2% and survival at 8 years with no evidence of disease (NED) was 77.2% with an overall survival rate of 90%. No difference in NED survival rate was found between Stage I and II. There was a tendency to better survival rate in those patients older than 50 years and also for post menopausal patients, however the difference did not reach statistical significance (66.7% NED survival at 8 years for premenopausal and 81.8% NED survival for post menopausal, also at 8 years, p = 0.056 Gehan). The time elapsed between surgery and radiation therapy (between 1 and 2 months) was found to be nonsignificant. Only 1 out of 171 patients had axillary dissection. The importance or lack of it, is discussed.

Utilidad de la PTH intraoperatoria como predictor de curación quirúrgica en hiperparatiroidismo primario

Serum PTH was measuredto all patients operated for PHPT between 2003 and 2008, before and five and ten minutes after theexcision of the parathyroid gland causing the disease. The criteria for complete cure were a normalserum calcium at 24 hours and 6 months after surgery and the pathological confirmation ofparathyroid gland excision.

Global Cancer Surgery, or Lack Thereof: A Wake-Up Call

The alarming predictions of the rising global cancer burden should not come as any surprise to the informed reader and must serve as a prompt and substantial wake-up call for anyone involved in the delivery of cancer care. A glimpse of the worrisome metrics associated with the rising global cancer burden is outlined in Table 1. The magnitude of the pervasive consequences of rising global cancer burden on the individual patient, as well as the nation and the entire world, are increasingly evident. Several attempts and initiatives are under way to address this rising global cancer burden by targeting various points in the global chain of cancer care delivery. To address any issue, one needs to be aware of the magnitude of the problem and the myriad deficiencies associated with its targeted amelioration. The Lancet Oncology Commission on Global Cancer Surgery is a laudable attempt to address the inequities in cancer care with particular emphasis on the gross lack of surgical care for patients afflicted with cancer. The article by Sullivan et al. follows in the footsteps of the Lancet Commission published in April 2015. The Lancet Commission outlined the heretofore grossly underestimated global surgical burden (defined as diseases that require a surgical procedure) and postulated various strategies to address the glaring deficiencies in our ability to provide high-quality and safe surgical care across the world. Because cancer is a leading cause of death, surpassed only by cardiovascular disease, it was thought that it required special emphasis. Following the similar structure of the article on global surgery, the article on global cancer surgery covers five main areas: examining the global burden of surgically amenable cancers, understanding the economic and financial issues surrounding cancer surgery, exploring the issues of strengthening surgical systems in different resource settings, performing an in-depth analysis of cancer research, and placing the issues and solutions for global cancer surgery in the highly variable political context of global health. The article highlights many issues across the spectrum of surgical care for cancer patients. The first issue of importance is the lack of awareness of the impending major onslaught of new cancer cases that require surgical procedures. It is expected that by the year 2030, 45 million surgical procedures will be needed. The gross inequity in the distribution of the new cancer cases (57 %) and cancerrelated mortality (65 %) affecting the lowto middle-income countries (LMICs) is not appreciated by many. The article clearly outlines the microeconomic and macroeconomic consequences to the individual patient and to the individual nation if the issues with access to surgical care are not addressed. At the microeconomic level, nearly 25–31 % of patients land on the slippery slope to financial bankruptcy after undergoing cancer surgery. At the macroeconomic level, the world will be on track to lose nearly

A New Scoring System for Gallbladder Cancer: The First Step of a Long Walk

12 trillion in gross domestic product between the years 2015 and 2030 due to cancer-related death and disability. The authors postulate financial and economic models to improve surgical care for cancer patients in a sustainable fashion. This includes approaches such as the ‘‘investment framework approach’’ and how to finance cancer surgery from public, private, or mixed sources. Tackling the problem of strengthening the surgical systems for cancer is extremely difficult, and the Lancet Commission rightfully propose a multisystem approach encompassing primary and community care providers; availability of high-quality imaging; access to reliable, reproducible, and credible pathologic services; and the ability to provide pain, palliative, and supportive services. Because the surgical systems across the world are highly Society of Surgical Oncology 2015

Differential expression profile of CXCR3 splicing variants is associated with thyroid neoplasia. Potential role in papillary thyroid carcinoma oncogenesis

In this issue of the Annals of Surgical Oncology Shukla et al. present us with a new scoring system to help in the decision process of the management of patients with gallbladder cancer. Gallbladder cancer is a silent disease, often diagnosed at an advanced stage, when the odds are against the patient for the most part. In some areas of the world such as northern India and Chile, this disease is highly prevalent, possibly due to the high prevalence of gallstones. In Chile, it represents the first cause of cancer death in women. Surgery is the only known curative treatment of gallbladder cancer, provided that a complete macroand microscopic tumor resection is achieved. The importance of a tool to predict resectability of gallbladder cancer patients derives from the fact that frequently these patients are found to have unresectable disease at the time of laparotomy. Until now, resectability of gallbladder cancer has depended greatly on the extension of the disease, ascertained both objectively and subjectively by the surgeon, and on his or her surgical ability, and is usually determined during the operation. Thus, an exploratory laparotomy could be considered a gold standard when it comes to assessing resectability, but the idea of a predictive score is to have reliable information before the operation, avoiding it in those cases that will not benefit from it. Thus, avoiding an unnecessary procedure would result in better patient management, and better administration of human and technical resources. In this regard, it would be a very useful tool. Ideally, a tool to predict the resectability of a tumor should be: (1) simple and easily performed, (2) cheap, (3) widely available, (4) precise, and (5) have a high negative predictive value. Shukla et al. propose such a scoring system. It is based on retrospective analysis of a series of 124 patients treated at Tata Memorial Hospital. With a 0–10 point score based on serum bilirubin, CA 19.9, and computed tomography (CT) scan findings, three groups of patients are identified: A, those highly likely to be resectable; B, those that may be resectable; and C, those highly likely to be unresectable. A testing sample of 335 patients was then retrospectively analyzed, seeking to correlate the prognostic score with the treatment actually offered to the patients; they found a highly significant correlation. The statistical methods used for the design of the score, however, are not described. In the 2004 abstract regarding the scoring system, a reference is made to the use of CA 19.9. The same group reports that there is a high correlation between radiological features, status of resectability, and CA 19.9. This suggests that CA 19.9 may not be an independent variable. The authors do not tell us whether a multivariate analysis was performed to ensure independence of CA 19.9. The fact is that we do not know the true contribution of this test to the overall prognostic score. Other variables were registered in the testing sample, but no further mention of them is made. Perhaps other biochemical markers besides those studied here are worthy of attention. While for the training sample 58% of the patients were considered amenable for surgery, in the testing sample this treatment was offered to 32.5% of the population. This underscores the heterogeneity of the cohorts, and, perhaps, calls for testing in a larger group of patients. Of the 109 patients operated in the testing sample, one would like to know how many Published online August 15, 2008. Address correspondence and reprint requests to: Augusto R. Leon, MD; E-mail: aleon@med.puc.cl

Papillary thyroid microcarcinoma: characteristics at presentation, and evaluation of clinical and histological features associated with a worse prognosis in a Latin American cohort

Papillary thyroid cancer (PTC) is the most prevalent endocrine neoplasia. The increased incidence of PTC in patients with thyroiditis and the frequent immune infiltrate found in PTC suggest that inflammation might be a risk factor for PTC development. The CXCR3-ligand system is involved in thyroid inflammation and CXCR3 has been found upregulated in many tumors, suggesting its pro-tumorigenic role under the inflammatory microenvironment. CXCR3 ligands (CXCL4, CXCL9, CXCL10 and CXCL11) trigger antagonistic responses partly due to the presence of two splice variants, CXCR3A and CXCR3B. Whereas CXCR3A promotes cell proliferation, CXCR3B induces apoptosis. However, the relation between CXCR3 variant expression with chronic inflammation and PTC development remains unknown. Here, we characterized the expression pattern of CXCR3 variants and their ligands in benign tumors and PTC. We found that CXCR3A and CXCL10 mRNA levels were increased in non-metastatic PTC when compared to non-neoplastic tissue. This increment was also observed in a PTC epithelial cell line (TPC-1). Although elevated protein levels of both isoforms were detected in benign and malignant tumors, the CXCR3A expression remained greater than CXCR3B and promoted proliferation in Nthy-ori-3-1 cells. In non-metastatic PTC, inflammation was conditioning for the CXCR3 ligands increased availability. Consistently, CXCL10 was strongly induced by interferon gamma in normal and tumor thyrocytes. Our results suggest that persistent inflammation upregulates CXCL10 expression favoring tumor development via enhanced CXCR3A-CXCL10 signaling. These findings may help to further understand the contribution of inflammation as a risk factor in PTC development and set the basis for potential therapeutic studies.

Impact of Preoperative Ultrasonographic Staging of the Neck in Papillary Thyroid Carcinoma

Objective We aimed to describe the presentation of papillary microcarcinoma (PTMC) and identify the clinical and histological features associated with persistence/recurrence in a Latin American cohort. Subjects and methods Retrospective study of PTMC patients who underwent total thyroidectomy, with or without radioactive iodine (RAI), and who were followed for at least 2 years. Risk of recurrence was estimated with ATA 2009 and 2015 classifications, and risk of mortality with 7th and 8th AJCC/TNM systems. Clinical data obtained during follow-up were used to detect structural and biochemical persistence/recurrence. Results We included 209 patients, predominantly female (90%), 44.5 ± 12.6 years old, 183 (88%) received RAI (90.4 ± 44.2 mCi), followed-up for a median of 4.4 years (range 2.0-7.8). The 7th and 8th AJCC/TNM system classified 89% and 95.2% of the patients as stage I, respectively. ATA 2009 and ATA 2015 classified 70.8% and 78.5% of the patients as low risk, respectively. Fifteen (7%) patients had persistence/recurrence during follow-up. In multivariate analysis, only lymph node metastasis was associated with persistence/recurrence (coefficient beta 4.0, p = 0.016; 95% CI 1.3-12.9). There were no PTMC related deaths. Conclusions Our series found no mortality and low rate of persistence/recurrence associated with PTMC. Lymph node metastasis was the only feature associated with recurrence in multivariate analysis. The updated ATA 2015 and 8th AJCC/TNM systems classified more PTMCs than previous classifications as low risk of recurrence and mortality, respectively.