Raffaella Benevento

Electrochemotherapy of cutaneous metastastes from breast cancer in elderly patients: a preliminary report.

BackgroundThe management of cutaneous metastases often represents a challenge because they may be widespread and may recur after radiotherapy or chemotherapy; breast cancer accounts for 51% of the total cases of cutaneous metastases. When surgical excision of chest wall recurrences is not possible and other local treatments such as radiotherapy or radiotherapy with hyperthermia fail, topical chemotherapy and electrochemotherapy (ECT) might be taken into account.ECT is a new local treatment of solid tumors which can be defined as the local potentiation, by means of permeabilizing electric pulses, of the antitumor activity of a non permeating anticancer drug with high intrinsic cytotoxicity.MethodsThis prospective observational study took place throughout March 2010 to October 2011. Twelve consecutive elderly patients (1 man and 11 women, median age of 76 years) with regional or distant skin or subcutaneous metastases from breast cancer, with or without visceral disease, were included in the study. Patient enrollment was carried out according to the ESOPE criteria. Bleomycin administration was followed by the application of brief electric pulses to each tumor nodule within 8 min after intravenous infusion of the drug. Electric currents were delivered by means of a 2–3 cm long needle electrode according to lesion size. All treatments were performed using the CliniporatorTM device.ResultsWe observed Complete Response(CR) in 75.3% (107 metastases), Partial Response(PR) in 17% (24 metastases), no change in 7.7% (11 metastases) . No serious ECT-related adverse events were reported; adverse events consisted of pain in the treated area one to two days after treatment (1 patient, 8.3%) and ulceration of treated area (1 patient, 8.3%).ConclusionECT could be suggested as a primary local therapy in patients not suitable for surgical removal of the primary tumor, and clinicians should not hesitate to use it even in the elderly.

Sutureless fixation with fibrin glue of lightweight mesh in open inguinal hernia repair: effect on postoperative pain: a double-blind, randomized trial versus standard heavyweight mesh.

BACKGROUND Open inguinal hernia repair is associated with a low incidence of complications that can be influenced by the type of mesh and its method of fixation. Our aim was to investigate the frequency and severity of postoperative pain and other complications when lightweight, large-pore meshes, compared with heavyweight, small-pore meshes, are fixed with human fibrin glue (HFG) during open inguinal hernia repair. METHODS A cohort of 80 patients undergoing open inguinal repair were enrolled. Forty patients received a lightweight and large porous mesh and 40 a standard heavyweight mesh with small pores. In all patients, HFG was used for mesh fixation. RESULTS Patients who received lightweight, large-pore mesh reported less pain than those in the control group both postoperatively (2.8 ± 1.1 vs. 4.9 ± 1.1; P = .0003) and at 1-month follow-up (1.7 ± 1.0 vs. 3.1 ± 1.0; P = .0038), and took fewer analgesics. There was no difference in days off work/activity. No differences were observed concerning postoperative complications. After 6 months there was no difference in groin pain between groups. CONCLUSION Patients who underwent open inguinal hernia repair with lightweight, large-pore mesh fixed with HFG experienced less pain throughout the first month after operation compared with those receiving standard mesh.

Preventive NPWT over closed incisions in general surgery: Does age matter?

Surgical site events (SSE), including surgical wound complications and surgical site infections, are a major concern in patients undergoing general surgery operations. These increase the costs of care, and can lead to prolonged hospital stay and need for further treatments, ultimately resulting in poor quality of life. Negative pressure wound therapy (NPWT) has been recently reported as a preventive strategy to avoid SSE, but little is known on the topic, and particularly in geriatric population. Our primary aim was to assess the efficacy of NPWT by means of a pocket device (PICO, Smith & Nephew, London, UK) in preventing SSE compared with conventional dressings in patients undergoing surgery with primary wound closure for breast and for colorectal diseases in our Unit. Our secondary aims were to assess the efficacy and safety of PICO in elderly patients, and to seek for differences between breast and abdominal results. All consecutive patients undergoing breast and colorectal surgery in our Unit between September 2012 and May 2014 were prospectively enrolled in this open label controlled study. Breast patients receiving NPWT were assigned to group B1, those receiving conventional dressings were assigned to group B2. Colorectal patients were assigned to group C1 (NPWT) and C2 (conventional dressings) in similar fashion. Each group included 25 patients, and at least 10 (40%) patients aged over 65 years to allow sub-analyses. NPWT significantly reduced SSE in both breast and colorectal patients compared with controls. No significant differences were observed according to age. Similar benefits were observed in breast and colorectal patients. Our results suggest that PICO is an effective tool to prevent SSE in patients undergoing general surgery, irrespective of age. Its use is recommended in frail, elderly patients at risk of SSE.

Granulomatous lobular mastitis: another manifestation of systemic lupus erythematosus?

Granulomatous lobular mastitis (GLM) is a benign disease of the breast generally affecting women of child-bearing age. Diagnosis is based on findings of noncaseating granulomatous inflammation at histologic evaluation of biopsy. GLM has been reported in association with infectious diseases (tuberculosis, bacterial, fungal, or parasitic infections), vasculitis (Wegener’s granulomatosis, sarcoidosis, giant cell arteritis, polyarteritis nodosa), foreign body reaction (e.g., breast implants), and oral contraceptive usage. When an apparent etiology cannot be found, GLM is defined as idiopathic. Pathogenesis is unknown, although an abnormal immune response has been hypothesized to underlie the development of this condition. Accordingly, we report here a case of GLM associated with a serological profile indicative of combined systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), clinically mimicking multifocal breast cancer (Fig. 1). A 65-year-old woman was referred to our Institution because of multiple nodular lesions in both breasts resembling multifocal cancer. Her past medical history was remarkable for a non-ST-elevation myocardial infarction (NSTEMI) occurred at age 40. Relevant laboratory tests included positivity for both ANA (1:1280, homogeneous + nucleolar pattern) and anti-dsDNA (indirect immunofluorescence on Crithidia luciliae), prolonged aPTT (67.7′′), detection of both anticardiolipin IgG (271 GPL U/mL; n.v.: <10) and anti-b2-glycoprotein I IgG (177 UA/mL; n.v.: <10), and consumed complement C4 (8 mg/dL; n.v.: 12– 52). Both patients’ breasts were subjected to excisional biopsy. However, contrary to the initial diagnostic suspicion, the patient was diagnosed as having granulomatous lobular mastitis (Fig. 2). The patient denied clinical complaints attributable to SLE/APS. No pregnancy morbidity/losses were reported during childbearing age. Physical examination was normal, apart from breast involvement. Cultures of breast tissue for bacterial, mycobacterial, and fungal pathogens were negative. Intradermal PPD was negative at a 72-hour

Interplay between membrane lipid peroxidation, transglutaminase activity, and cyclooxygenase 2 expression in the tissue adjoining to breast cancer.

Breast cancer, a leading cause of cancer related deaths worldwide, is one of the most common neoplasms in women. The increased generation of reactive oxygen species (ROS) in breast lesion is critically involved in the mutagenic processes that drive to breast carcinoma initiation and progression. To date, the molecular events occurring in the tissue adjoin the cancer lesion have not been elucidated. Here, we investigated the role of excess ROS generation during human breast carcinogenesis by evaluating oxidative stress biomarkers, tissue transglutaminase (t‐TGase) activity, and expression levels of ubiquitin and cyclooxygenase‐2 (COX‐2) in the normal tissue adjoin to fibroadenoma (nFA), atypical ductal hyperplasia (nADH), and invasive ductal carcinoma (nIDC) from 45 breast cancer patients. We found that lipid peroxidation and nitric oxide production significantly increased in nIDC respect to nFA and nADH (P < 0.005) whereas the 4‐hydroxy‐2‐nonenal (HNE) protein‐adducts increased only in nADH (P < 0.005). The increased lipid damage observed in nIDC correlates with estrogen receptor exposure in IDC (R2 = 0.89). Moreover, nIDC and invasive ductal carcinoma (IDC) showed a 10‐fold higher t‐TGase activity compared to nFA and nADH. Contrary, COX‐2 expression levels significantly decreased nIDC and IDC respect to the nFA and nADH (P < 0.001). The analysis of the free ubiquitin expression revealed equal levels in nADH and nIDC samples whereas high molecular weight‐ubiquitin conjugate increased about fivefold only in nIDC (P < 0.01 vs. nADH). These novel findings reveal an interplay between membrane lipid peroxidation, t‐TGase activity, and COX‐2 expression levels in the tissue adjoining to neoplastic lesion during breast cancer progression. J. Cell. Physiol. 227: 1577–1582, 2012.

Angiosarcoma of the breast: a new therapeutic approach?

Highlights • We report the case of a 76-year-old woman who developed an exuberant and aggressive post radiation angiosarcoma of the breast and discuss different aspects of therapy for this disease.• The lesions into the chest wall, and multiple abdominal skin nodules were treated with local Electrochemotherapy (ECT) with intravenous bleomicin.• Treatment with ECT in addition to systemic chemotherapy achieves a complete response in all the lesions and improving patient body image perception.

Electrochemotherapy of head and neck cancer in elderly patients: a preliminary report.

Background Locoregional recurrence is the most common cause of failure after head and neck cancer surgery and results in significant morbidity including effects on speech and swallowing and on cosmetic disfigurement [1]. Increasing age itself is an important risk factor for surgical treatment, and older people have coexisting medical conditions that can adversely affect surgical care and outcomes, and these must be taken into consideration. When surgical excision is not possible there are several therapeutic options.[2] Electrochemotherapy (ECT) is defined as a local treatment which, via cell membrane permeabilising electric pulses, potentiates the cytotoxicity of non permeant or poorly permeant anticancer drugs with high intrinsic cytotoxicity at the site of electric pulse application. Electroporation transiently permeabilizes tumor cell membranes, thus enabling diffusion of a chemotherapeutic drug into the cells and increasing its cytotoxicity. The most frequently used drugs are bleomycin and cisplatin. Association with electroporation induces a cytotoxicity increase of up to 80-fold for cisplatin and up to 8000-fold for bleomycin. Intravenous bleomycin is administered at the dose of 15.000 IU/m2, in bolus. ECT has significantly higher effectiveness than chemotherapy alone. [3]

The role of sentinel node biopsy (SNB) in elderly breast cancer patients

Background Aged patients suffering from breast cancer are often “undertreated” because of their presumed shorter life expectancy, increasing comorbidity, and favorable tumor biology. The Consensus Conference Panel of Philadelphia recommends SNB in patients with breast tumours ≤3 cm., although some authors have reported that this technique is reliable also in elderly patients with larger tumors. The aim of this study was to assess the safety of the procedure as well as the rate of axillary recurrences after SNB in a series of old population.

Efficacy of percutaneous radiofrequency ablation (RFA) for hepatocellular carcinoma in elderly patients

Background HCC is the most common complication of liver cirrhosis, and the incidence of HCC increases with age in cirrhotic patients. The treatment of HCC in elderly subjects allows for some considerations. Hepatic resection can be safely done in cirrhotic HCC patients aging > 70 years, but the prognosis of these patients is less favorable than < 70 years patients, even when curative resection is achieved. Liver transplantation is an exceptional measure for elderly patients, because they have a high incidence of concurrent diseases and are usually considered a highrisk group for major surgery. Radiofrequency ablation, alcohol injection and transcatheter arterial chemoembolization are not surgical treatments for HCC that are currently performed in elderly patients.

Treatment with radiofrequency thermoablation of elderly patients suffering from hepatocarcinoma (HCC)

Results The average follow-up was 16 months (range 8–42). The complete tumor necrosis was achieved in 25 patients, (in 19 cases with a single intervention and in 6 cases with two intervention). In the remaining 5 patients only a partial necrosis was obtained, and they were submitted to a second treatment. No serious complications (haemorrhage, hemoperitoneum, acute liver failure) were detected in the post-operative period. The average time of the procedure was 15 minutes (range 12–60). All patients were discharged the day after the treatment and expressed satisfaction about this technique. The total costs were less than surgical treatment (less time of hospitalization and less complications).