Matteo Lavazza

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.

Transoral endoscopic thyroidectomy via vestibular approach: operative steps and video

In this video we describe transoral endoscopic thyroidectomy vestibular approach (TOETVA). Inclusion criteria are (I) patients who had a ultrasonographically (US) estimated thyroid diameter not larger than 10 cm; (II) US estimated gland volume ≤45 mL; (III) nodule size ≤50 mm; (IV) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (V) follicular neoplasm; (VI) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through three-port technique placed at the oral vestibule, one 10-mm port for 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sterncleidomuscles. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments and intraoperative neuromonitoring (IONM).

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.

Transoral thyroidectomy: why is it needed?

Transoral thyroidectomy (TOT) represents reasonably the desirable minimally invasive approach to the gland due to the scarless non-visible incisions, the limited distance between the gland and the access that minimize tissue dissection and respect of the surgical anatomical planes. Patients are routinely selected according to an extensive inclusion criteria: (I) ultrasonographically (US) estimated thyroid diameter not larger than 10 cm; (II) US gland volume ≤45 mL; (III) nodule size ≤50 mm; (IV) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (V) follicular neoplasm; (VI) papillary microcarcinoma without lymph node metastasis. The operation is realized through median, central approach which allows bilateral exploration of the thyroid gland and central compartment. TOT is succeed both endoscopically adopting ordinary endoscopic equipments or robotically. In detail three ports are placed at the inferior oral vestibule: one 10-mm port for 30° endoscope and two 5-mm ports for dissecting, coagulating and neuromonitoring instruments. Low CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sterncleidomuscles similar to that of conventional thyroidectomy. TOT is now reproducible in selective high volume endocrine centers.

Neuromonitoring in endoscopic and robotic thyroidectomy

Intraoperative neuromonitoring (IONM) has proven effective for intraoperative verification of RLN function in the conventional thyroid surgery. However, no studies have performed a systematic evidence-based assessment of this novel health technology in endoscopic and robotic thyroidectomy. Evidence-based criteria were used in a systematic review of relevant literature for years 2000–2015. Four electronic databases (CENTRAL, MEDLINE, Cochrane and EMBASE) were used to retrieve relevant reports published from January 1, 2000 to September 1, 2016. The search terms included “endoscopic thyroidectomy”, “robotic thyroidectomy”, “IONM”, “continuous IONM (CIONM)”, “neural monitoring”, “recurrent laryngeal nerve monitoring”, and “superior laryngeal monitoring”. The following data were retrieved from eligible studies of patients undergoing endoscopic or robotic thyroidectomy: objective of study, design and setting of study, population, intervention examined, quality of data, follow-up and dropout rate, risk of bias, and outcomes assessed. Of 160 studies retrieved, only 9 (5%) studies used IONM. Eight studies reported 522 nerve at risk (NAR) with IONM. Only three were prospective randomized studies. Reports of IONM endoscopic and robotic procedures included their use for re-surgery and use in both benign and malignant cases. None of the IONM endoscopic procedures involved bilateral palsy. Two studies reported the use of a staged strategy. The rates of recurrent laryngeal palsy were 0–3.6% for transient and 0–0.4% for permanent. Only 30% of the studies performed vagus nerve stimulation, and only 25% performed superior laryngeal nerve monitoring. In addition to the use of IONM as an assistive technology for navigating the anatomy in challenging procedures such as endoscopic and robotic thyroidectomy, IONM has potential use as a routine adjunct to the conventional video-assisted nerve identification in thyroidectomy.

Usefulness of CBCT and guidance software for percutaneous embolization of a lymphatic leakage after thyroidectomy for cancer

Lymphatic leakage can develop as an iatrogenic complication of thoracic, cardiac, and neck surgery. The management of this complication may be challenging and involves more specialists. Percutaneous, image-guided techniques may offer two advantages: mini-invasivity and ability to image and identify the anatomy and the site of the leakage. We report a case of refractory cervical chylous leakage after thyroidectomy and lymphadenectomy for cancer that was successfully treated with an ultrasound-guided intranodal lymphangiography and a percutaneous puncture of the leak performed using CBCT as imaging guidance.

Standardizing or Tailoring Bariatric Surgery

It is well known how obesity has a complex and multifactorial pathogenesis and represents a major risk factor for various metabolic, cardiovascular, respiratory, articular, and gastrointestinal diseases. On this regard, it is clear how evaluation and treatment of obese patients must to be interdisciplinary and integrated. Moreover, bariatric surgery consists of different types of operations carried out through different techniques, the main ones being of restrictive or malabsorbitive. In a previous letter [1], we focused on the need of standardization in bariatric surgery in relation to the age of the patient. Facing the heterogeneous aspects of obesity and its overall and surgical treatment, we may ask whether it is still worthwhile to talk about and look for standardization or it is better to consider bariatric surgery as a patient-tailored treatment. It is undoubtedly mandatory to look for standardization of different surgical techniques to allow reproducibility and comparability and to minimize complications. Nevertheless, if we mainly consider the indications of each type of procedure, do we really feel a need for standardization? Or maybe, are we asked to strictly tailor the best surgical procedure on the specific features of the patient? The obese patient may present sometimes a kaleidoscopic variety of clinical features that must be taken into account when planning the better surgical treatment. Classic anthropometric parameters, with all the limits of sensitivity related to BMI, are not the only ones that must be considered [2]. Eating habits, age, psychologic profile, related morbidity, ASA score, presence of hiatal hernia and gastroesophageal reflux, gastritis, gastric precancerous lesions, symptomatic cholelitiasis, bowel inflammatory disease, and previous abdominal surgery must also be taken into account. All the above-cited issues may impact on the choice of the more appropriate therapeutic way to follow and particularly of the more appropriate surgical procedure available. Sequentiality of treatment is another element to evaluate in the complex and articulated decision-making process. Obesity is a chronic disease; hence, its treatment cannot be a one-shot procedure limited in time. Redo surgery must not be considered always a failure of the primary surgery but in many cases must be interpreted as a normal step-by-step pathway in obesity treatment, above in all in young patients. In conclusion, we must discern the need of surgical technique standardization from the need to standardize the choice of surgical procedure type that we want to propose to the patients. The high complexity of the obese patients suggests that the type of surgery must be carefully calibrated on their overall clinical features evaluated during preoperative workup. The aim of standardizing the indications supposing the use of algorithms seems at least difficult to perform and quite far from everyday clinical practice.

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.

N staging system: tumor-node-metastasis and future perspectives

The correct staging of disease, with an exact definition of the extent of cancer at the diagnosis, is crucial in the planning of a specific treatment and in the assessment of real chances of cure. Cancer staging systems are expected to be accurate in the description of the severity of a patients tumor on the basis of the extent of the primary neoplasm and of its spread, thus giving clinician tools to estimate prognosis and providing objective parameters to compare groups of patients in clinical studies. This last point is of wide importance in evaluating successful treatment strategies in oncology, and this is one of the issues that contributed to the development of stage-adapted therapies.