Corrado Chiappa

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.

Peri-operative blood transfusion in gastric cancer surgery: prognostic or confounding factor?

BACKGROUND AND PURPOSE The relationship between peri-operative blood transfusions (PBTs) and poor prognosis in gastric cancer (GC) patients is still debated. The aim of this study is to examine the real prognostic impact of PBTs in comparison to well-known prognostic factors. METHODS We retrospectively analyzed a series of 224 patients who underwent surgery with curative intent for GC from January 1995 to December 2011. Among 224 patients, 46 (20%) required PBTs. RESULTS The overall 5-year survival was 77% in non-transfused patients and 65% in patients who received PBTs (p = 0.03). PBTs did not further stratify any recognized prognostic category (such as pT or pN according to the 7th edition of the TNM staging system). Multivariate analysis including all known prognostic variables (both cancer- and non-cancer-related) did not select PBTs as an independent prognostic factor. Only preoperative hemoglobin and albumin level, pT and operative time were significantly associated with the requirement for PBTs. CONCLUSIONS The study showed a worse prognosis for transfused patients, but PBTs seem a confounding factor more than a prognostic indicator, as they are obviously affected by other variables.

Impact of static cold storage VS hypothermic machine preservation on ischemic kidney graft: inflammatory cytokines and adhesion molecules as markers of ischemia/reperfusion tissue damage. Our preliminary results

At the present time, deceased heart-beating donor kidney allografts are usually stored cold. Extended-criteria donor (ECD) grafts show higher sensitivity to ischemia-reperfusion damage than standard kidneys. The increasing use of marginal organs in clinical transplantation urgently requires a more effective preservation system. Pulsatile hypothermic machine perfusion has shown major advantages over static cold storage in terms of reduced organ injury during preservation and improved early graft function. This preliminary study aims to compare pulsatile hypothermic machine perfusion and static cold storage of kidney allografts, outlining differences in the levels of early inflammatory cytokines (TNF-α, IL-2 and IL-1β) and soluble intracellular adhesion molecule (sICAM-1) in perfusion and preservation liquid.

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.

The role of Micrometastatic Disease in Sentinel Lymph Node in Breast Cancer

Abstract:  Sentinel lymph node (SLN) biopsy is the standard procedure for axillary node staging in breast cancer. Improvements in histopathological analysis and immunohistochemistry have recently increased the rate of detection of lymph nodal micrometastases. The clinical implications and prognostic significance of micrometastases in SLN still remain a controversial issue. Literature review was analyzed by searches of Medline and PubMed data bases. Whereas most studies carried on small groups of patients did not show differences in survival, recently some studies with longer follow‐up and with larger populations demonstrated that prognosis of patients with micrometastases is worse compared to that of patients with SLN free of disease. To date, completion axillary dissection remains the standard option when a macro or micrometastasis (0.2–2 mm) in the SLN is found. However, in absence of level‐1 evidence guidelines, each case requires discussion in the context of a multi‐disciplinary team.

Prognosis and treatment of patients with positive peritoneal cytology in advanced gastric cancer.

Positive peritoneal cytology in gastric cancer is classified as M1 disease by the 7(th) Edition of American Joint Committee on Cancer staging system. With the introduction of laparoscopy and peritoneal washing cytology in the staging of gastric cancer a new category of patients has been identified. These are patients with no macroscopic peritoneal metastases but with peritoneal cytology positive (P0C1). Prognosis and treatment of such patients represent a controversial issue. We evaluate the state of the art of staging system in gastric cancer and discuss standardisation in staging and treatment procedures. There is still a lack of uniformity in the use of laparoscopy with peritoneal cytology in clinical decision making and in the surgical treatment for gastric cancer. Survival of this patient subset remains poor. Multimodal therapies and new therapeutic strategies are required to improve the survival of these patients.

Treatment of aortoiliac occlusive or dilatative disease concomitant with kidney transplantation: how and when?

BACKGROUND AND PURPOSE Aortoiliac (AI) lesions (both dilatative and occlusive) can occur in kidney allograft recipients. The correct timing of vascular imaging and treatment is controversial. Aim of the present paper is to report our experience. METHODS between January 2010 and December 2012, 106 patients included in our waiting list for kidney transplant underwent computed tomography (CT) angiogram to study AI axis. In 21 cases an AI lesion was identified before transplant. In 3 cases surgery was mandatory before kidney transplant, and in 18 cases lesions were treated simultaneously with kidney transplantation. MAIN FINDINGS AI pathology distribution was as follows: 15 iliac stenoses treated with thromboendarterectomy (TEA), 2 Leriche syndrome and 1 aortic aneurism treated with an aortobisiliac bypass (AI-BP), and 3 aneurysms treated with endovascular aortic repair (EVAR). In two cases a postoperative hematoma occurred. In one case occlusion of a stent-graft branch was treated with a femoro-femoral crossover bypass and transplant was then performed on the contralateral iliac axis. Perioperative mortality was 0%, and graft survival rate was 100% at 1 year in all cases. CONCLUSIONS A CT angiogram is useful in order to detect AI lesions and to be able to evaluate the best treatment option for the kidney transplantation and the correct timing for additional vascular surgery. The EVAR procedure should be safe, and does not compromise anastomosis success and graft survival, with less postoperative complications than open surgery.

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.