Marc Thill

Intraoperative assessment of surgical margins during breast conserving surgery of ductal carcinoma in situ by use of radiofrequency spectroscopy

Assessment of margins when excising ductal carcinoma in situ (DCIS) of the breast is difficult. Frozen section is unreliable and specimen intraoperative radiography only provides information regarding the extent of the visualized lesion or the microcalcifications. A multi-center, single arm study was conducted to evaluate the benefit of a novel device (MarginProbe) in intraoperative margin assessment during breast conserving surgery (BCS) of DCIS, and the associated reduction of re-excisions. We present results for 22 patients, from those enrolled in our institution. The device was used as an adjunctive tool to current practice. Based on permanent histology reporting, the rate of successful procedures was 86%. The improvement in intraoperative assessment with device use was associated with a reduction in re-excision rates, from 38.8 to 18%.

Expression of vitamin D receptor (VDR), cyclooxygenase-2 (COX-2) and 15-hydroxyprostaglandin dehydrogenase (15-PGDH) in benign and malignant ovarian tissue and 25-hydroxycholecalciferol (25(OH2)D3) and prostaglandin E2 (PGE2) serum level in ovarian cancer patients.

Ovarian carcinomas are associated with increased inflammation which is based upon an up-regulation of inducible cyclooxygenase-2 (COX-2). Moreover, based on our previous published data, the extra-renal vitamin D metabolism seems to be dysregulated in comparison to healthy tissue. In order to gain further insight into the prostaglandin (PG)- and vitamin D-metabolism in ovarian carcinomas, the study aimed to evaluate the expression of the PG metabolising enzymes COX-2 and 15-hydroxyprostaglandin dehydrogenase (15-PGDH) compared to the vitamin D receptor (VDR) in benign and malignant ovarian tissues. Additionally, we determined the 25-hydroxycholecalciferol (25(OH2)D3) serum levels. Expression of VDR, COX-2 and 15-PGDH was determined by Western blot analysis. Serum levels of 25(OH2)D3 and PGE2 were measured by chemiluminescence-based and colorimetric immunoassay. We detected significantly higher expressions of the PG metabolising enzymes 15-PGDH and COX-2 in malignant tissue and PGE2 serum levels were 2-fold higher in tumour patients. Furthermore, we found an inverse correlation to the VDR-expression which was 62.1% lower in malignant tissues compared to that in benign tissues. Surprisingly, we could not detect any differences between the 25(OH2)D3 serum levels in either group (n=20). These data suggest a correlation between PG- and vitamin D-metabolism in ovarian carcinomas.

Successful laser therapy of a papular acantholytic dyskeratosis of the vulva: case report and review of literature

BackgroundThe papular acantholytic dyskeratosis summarizes a collection of papular skin lesions which occur in intertriginous areas and in the genital area. They show a very characteristic histology without the connection to a syndrome such as the Hailey–Hailey disease or the Darier disease.MethodsWe present the case of an affected 45-year-old woman and evaluate the laser therapy as therapeutic option.ResultsA long lasting reduction of the symptoms was achieved by paying special attention to involving the deep tissue layers while performing the laser therapy. Despite causing a long and painful healing process, this was the only way to achieve a lasting reduction of the symptoms.ConclusionsLaser therapy in afflicted areas can improve the symptoms of the papular acantholytic dyskeratosis. The deep tissue laser therapy showed more success than the superficial laser therapy.

Intraoperative assessment of margins in breast conservative surgery--still in use?

A positive margin in breast conserving surgery is associated with an increased risk of local recurrence. Failure to achieve clear margins results in re‐excision procedures. Methods for intraoperative assessment of margins have been developed, such as frozen section analysis, touch preparation cytology, near‐infrared fluorescence optical imaging, x‐ray diffraction technology, high‐frequency ultrasound, micro‐CT, and radiofrequency spectroscopy. In this article, options that might become the method of choice in the future are discussed. J. Surg. Oncol. 2014 110:15–20.

Diagnosis and treatment options of vulvar cancer: a review

IntroductionVulvar cancer is a rare malignancy in women. However, within the past decade, a distinct increase in the incidence of vulvar intraepithelial neoplasia (VIN) as a precursor lesion, and an increase of vulvar cancer have been reported within Europe and the USA. Surgery is the first choice in treating patients with vulvar cancer, especially in its early stages. In an attempt to decrease the incidence of complications, research was made into modifications of the surgical procedure without compromising the prognosis. The replacement of radical vulvectomy by less wide local excision is one of these modifications. As vulvar cancer is relatively rare, it is possible to give evidence-based treatment recommendations, but usually on a low evidence level. Aim of this paper is to elucidate diagnostics and surgical treatment options in the management of vulvar cancer.Materials and methodsWe searched major databases (i.e. pubmed) with the following selection criteria: vulvar cancer, en bloc resection, triple incision, and sentinel node biopsy.ConclusionsToday, the operative therapy is much less radical and more emphasized on individualized therapeutic concepts. The tendency is to leave the ultraradical surgical options which suffer from high morbidity towards less radical, minimal invasive techniques. Due to the rarity of the disease further studies will have to be performed by international collaborative groups.

MarginProbe® – Final results of the German post-market study in breast conserving surgery of ductal carcinoma in situ

The goal in breast conserving surgery (BCS) of ductal carcinoma in situ (DCIS) is removal of the tumor with a clear surgical margin. However, re-excision rates are regrettably high. To date, there are no adequate procedures for intraoperative margin assessment of DCIS. A multicenter, single arm study was conducted to evaluate the benefit of a novel device (MarginProbe®) in intraoperative margin assessment during BCS of DCIS, the associated reduction of re-excisions and the cosmetic outcome of the treated patients. We present results of 42 patients enrolled in 3 German institutions. The device was used as an adjunctive tool to standard of care. The device use was associated with a reduction in re-excision rates by 56%, from 39% to 17% (p = 0.018).

Cancer in pregnancy. Part I: basic diagnostic and therapeutic principles and treatment of gynecological malignancies

PurposeCancer in pregnancy is a rare circumstance. However, the coincidence of pregnancy and malignancy is supposed to increase due to a general tendency of postponing childbearing to older age. To date, clinical guidelines are scarce and experience regarding therapeutic management is limited to case reports.MethodsThis review focuses on general diagnostic and therapeutic principles including systemic therapy for malignancies in pregnancy.ResultsIn part I, we report on diagnosis and therapy of gynecological tumors.ConclusionThe diagnosis of gestational cancer faces both oncologist and obstetrician to the dilemma of applying appropriate diagnostic techniques and adequate local and systemic therapy to an expectant mother without harming the fetus.

Emerging gonadotropin-releasing hormone agonists

Introduction: Gonadotropin-releasing hormone agonist analogs (GnRHa) are peptides that mimic the action of gonadotropin-releasing hormone (GnRH) and are used to suppress subsequent sex steroid production. Although the analogs are a rather defined group of drugs, there have been developments in the past decades and there is still ample room for improvement. New therapeutic strategies in the use of GnRHs are discussed. Areas covered: Major points of discussion include: i) the use of concomitant treatment of early breast cancer in premenopausal estrogen-positive and -negative patients, ii) the use of GnRHa for fertility preservation in young female patients with malignant diseases and iii) the use of GnRH analogs in assisted reproduction. The manuscript provides a better understanding of GnRH agonists as well as an explanation of their major indications, biochemical pathways and concluding therapeutic strategies. Recent results from international meetings and debates are described to explain current controversies. Expert opinion: This paper highlights the need for more complex GnRH analogs. In the next few years, there will be longer acting GnRHas that may improve adherence. New therapeutic targets in oncological concepts may go beyond fertility preservation and focus on the antiproliferative effects of GnRH analogs.

Successful application of vacuum-assisted closure therapy for treatment of mastitis-associated chronic breast wounds

IntroductionAlthough non-puerperal mastitis is rare and its cause is rather unclear, the number of patients diagnosed with this defect is increasing. In some cases, standard therapy fails and it progresses to a chronic disease. Vacuum-assisted closure (VAC) therapy has shown good results in healing complex wounds.Patients and methodsThe goal of this study was to evaluate our experiences with VAC therapy and to answer the question whether or not should be accepted as an effective treatment in healing chronic wounds caused by non-puerperal mastitis. Retrospectively, we identified five patients with a non-puerperal mastitis chronic wound that was treated using VAC and report on their outcome.ResultsWe reached both wound control and closure of the breast wounds in all patients.ConclusionAccording to our findings, the VAC therapy can be considered when managing challenging breast wounds, particularly when other therapeutic options have failed. The role of VAC therapy as a primary therapeutic option has not yet been evaluated.

New technologies in breast cancer surgery.

Since breast-conserving surgery has become the gold standard for early breast cancer, the development of less radical or less burdensome technologies has been pressed for in order to preserve the patient from unnecessary harm through the operative procedure. Different technical approaches are under evaluation, and some of them are already being used in the clinical setting. The aim of this article is to present a perspective on future breast cancer surgery by shedding light on the current innovative and new techniques.