Surgical therapy of bone metastases

The treatment of patients with cancer epitomizes the importance of using a collaborative team approach to optimize patient care. Physician team members most commonly are radiation oncologists, general surgeons, surgical oncologists, thoracic surgeons, neurosurgeons, and orthopedic surgeons. When patients are receiving chemotherapy, their medical oncologist frequently takes responsibility for coordinating care among the various team members and initiating consultations with necessary providers. When patients develop bone metastases or chemotherapy-induced bone loss (CTIBL), the orthopedic surgeon may be able to improve the patient's quality of life greatly. Procedures orthopedists perform most commonly include open reduction and internal fixations and arthroplasties (joint replacement surgery). Less invasive procedures currently being tested include stereotactic radiosurgery, radiofrequency ablation (RFA), and percutaneous cementoplasty. By understanding the options available to patients with skeletal complications of malignancy, the medical oncologist can discuss issues with patients and make appropriate referrals for diagnosis and treatment. Additionally, with a greater understanding of the surgical procedures available, the medical oncologist will be better able to assist in preparing the patient for surgery.     

Robotic Surgery in Cancer Care: Opportunities and Challenges

Malignancy-associated mortality, decreased productivity, and spiritual, social and physical burden in cancerpatients and their families impose heavy costs on communities. Therefore cancer prevention, early detection, rapiddiagnosis and timely treatment are very important. Use of modern methods based on information technology incancer can improve patient survival and increase patient and health care provider satisfaction. Robot technologyis used in different areas of health care and applications in surgery have emerged affecting the cancer treatmentdomain. Computerized and robotic devices can offer enhanced dexterity by tremor abolition, motion scaling,high quality 3D vision for surgeons and decreased blood loss, significant reduction in narcotic use, and reducedhospital stay for patients. However, there are many challenges like lack of surgical community support, large size,high costs and absence of tactile and haptic feedback. A comprehensive view to identify all factors in differentaspects such as technical, legal and ethical items that prevent robotic surgery adoption is thus very necessary.Also evidence must be presented to surgeons to achieve appropriate support from physicians. The aim of thisreview article is to survey applications, opportunities and barriers to this advanced technology in patients andsurgeons as an approach to improve cancer care.     

Micro ear surgery—Its purpose and procedure for tubo tympanic pathology

Hearing is one of the special senses god has bestowed upon human beings. One can really appreciate the value of hearing only when one ceases to hear. Unfortunately, in our country the hearing impaired individuals are ridiculed, where as the visually impaired are sympathized upon. Our country being a developing nation with poor socio-economic status and low environmental surroundings, chronic diseases of the ear account for nearly 5% of the population. One will not be surprised if the statistics reveal five crores chronic ear patients in our country. If this ailment is not corrected, the hardship faced by the patients will be tremendous. Hence, the purpose of ear surgery is to restore normal anatomical and physiological status of the ear, so that the patient leads a comfortable lifestyle. ENT surgeons by performing corrective surgery for chronic suppurative otitis media (CSOM) can change the lifestyles of their patients profoundly. The medical line of management will only lessen the severity of symptoms. With the present modern gadgets coupled with skill acquired by otologist. I will exhort every patient with CSOM to undergo corrective ear surgery as to ensure a healthy and normal life.     

Correlates of referral practices of general surgeons to plastic surgeons for mastectomy reconstruction

BACKGROUND: General surgeons' attitudes toward breast reconstruction may affect referrals to plastic surgeons. The propensity to refer to plastic surgeons prior to surgical treatment decisions for breast cancer varies markedly across general surgeons and is associated with receipt of reconstruction. In this study, the authors used data from a large physician survey to examine factors associated with general surgeons' propensity to refer breast cancer patients to plastic surgeons prior to mastectomy. METHODS: The authors surveyed all attending general surgeons (N=456 surgeons) from a population-based sample of breast cancer patients who were diagnosed in Detroit and Los Angeles during 2002 (N=1844 patients), with a surgeon response rate of 80%. The dependent variable was surgeon report of the percentage of their mastectomy patients in the past 2 years who they referred to plastic surgeons prior to initial surgery (referral propensity). Referral propensity was collapsed into 3 categories (<25%, 25-75%, and >75%) and regressed on the following covariates using logistic regression: Surveillance, Epidemiology, and End Results registry; number of years in clinical practice; surgeons' sex; annual breast surgery volume; and hospital setting. RESULTS: Only 24% of surgeons referred>75% of their patients to plastic surgeons prior to surgery (high referral propensity). High referral propensity was associated independently with surgeons who were women (odds ratio [OR], 2.3; P=.03), high clinical breast surgery volume (OR, 4.1; P<.01), and working in cancer centers (OR, 2.4; P=.01). High-referral surgeons and low-referral surgeons also had different beliefs about women's preferences for reconstruction, with the low-referral surgeons perceiving more access barriers (cost, availability of plastic surgeons) and a lower patient priority for reconstruction. CONCLUSIONS: A large proportion of surgeons do not refer breast cancer patients to plastic surgery at the time of surgical decision-making. Surgeons who have a high referral propensity are more likely to be women, to have a high clinical breast volume, and to work in cancer centers. These data support the importance of comanagement through multidisciplinary care models. Women need more opportunities to discuss reconstructive options to make informed surgical treatment decisions about their breast cancer.     

Clinicopathological Features and Complications of Thyroid Operations: A Single Centre Experience

Thyroid surgery evolution is important with a lots of hurdles faced by many surgeons to reach the present stage. The complications from the olden days reduced with improvement in understanding the disease process, development of antibiotics, anaesthesia and now restricted mainly to hypoparathyroidism and recurrent laryngeal nerve injuries. A retrospective analysis of thyroid surgeries performed at BP Koirala Institute of Health Sciences centre from 2007 to 2011 Clinicopathological features and complications were analyzed. Among 203 patients who underwent surgery for thyroid operations, 53 were malignant and 150 were benign cases. Hemithyroidectomy was the most common procedure performed (118 cases). Papillary thyroid cancer was the most common malignant lesion and colloid goiter the most common benign lesion. Postoperative complications occurred in 12 patients—infection in two patients, bleeding requiring reexploration in one patient, hypocalcemia in 6 (5-transient and 1-permanent) and hoarseness of voice in three patients (2-temporary and 1-permanent). FNAC is an easy, cost effective, reliable investigation in experienced hands. Reoperation, primary stage of the tumor and central node dissection are associated with increased complication rates.     

腮腺多形性腺瘤外科术式的演变及发展

腮腺肿瘤以多形性腺瘤居多,目前外科治疗仍是主要的治疗方式。20世纪时学者们由于对面神经解剖和多形性腺瘤包膜病理特性缺乏了解,该病的主要术式为单纯肿瘤剜除术,但术后容易导致复发;试图通过扩大切除的范围控制复发率,于是包膜外切除术开始运用于临床,虽然切除了肿瘤的包膜,但是复发率仍未能很好地控制。腮腺浅叶切除术和腮腺全切术明显降低了复发率,但是伴随着面神经损伤的加重,似乎又矫枉过正。腮腺部分切除术作为新的腮腺手术形式,不但降低了复发率、面神经损伤率,还得到病理学基础研究证据的支持,是目前较为先进的手术方式。但是在经典的腮腺浅叶切除术与先进的腮腺部分切除术之间仍存在争议。经过整形学、病理学、基因检测法等方面探究这两种手术的优劣均各有差异。本文从腮腺术式的演变历程探讨腮腺术式发展的方向。      

Lateral ligament: its anatomy and clinical importance

Since Miles proposed abdominoperineal excision as a radical surgery for rectal cancer in 1908, surgeons have recognized the lateral ligament in the pararectal space of their patients and attached clinical importance to it, although anatomists did not describe any such configuration in cadavers. By analyzing an experience of 421 lower rectal cancer cases at the Cancer Institute Hospital in Tokyo, discussion of the lateral ligament was focused on its relationship to the fascial arrangements in the pelvis, the pelvic autonomic nervous system, and the lymphatic drainage of the rectum. The lateral ligament is not an anatomical term, but a clinical or surgical one. It exists in a living pelvis as a condensation of connective tissue around the middle rectal artery and is divided into two segments by the inferior hypogastric nerve plexus inside it and the visceral endopelvic fascia around it. The lateral ligament is a pathway of blood vessels and nerve fibers toward the rectum and lymphatic vessels from the lower rectum toward the iliac lymph nodes. Therefore, the lateral ligament plays a critical role in surgery for lower rectal cancer in two respects: the anatomic extent of resection for curing rectal cancer, and the preservation of sexual function.     

Correlates of patient satisfaction and provider trust after breast-conserving surgery

BACKGROUND: Although breast-conserving therapy (BCS) is considered the standard of care for early-stage breast cancer, up to 20% of patients are dissatisfied. The effect of treatment-related factors on patient satisfaction with their healthcare experiences is unclear. METHODS: All BCS patients at the University of Michigan Medical Center who were treated between January 2002 and May 2006 were surveyed (n=714; response rate, 79.5%). Patients were queried regarding 4 aspects of their decision for surgery: satisfaction with the decision, decision regret, decisional conflict, and trust in surgeons. Independent variables included the number of re-excisions, the occurrence of postoperative complications, and postoperative breast appearance, which was assessed by using the Breast Cancer Treatment and Outcomes scale. Multiple logistic regression was used to assess the effect of the independent variables on each outcome controlling for demographic and clinical characteristics. RESULTS: Breast asymmetry after BCS was correlated significantly with patient satisfaction with their treatment experiences and patient distrust in surgeons. Women who reported pronounced asymmetry were significantly less likely to be satisfied with the decision for surgery compared with women who reported minimal asymmetry (odds ratio [OR], 0.43; 95% confidence interval [95% CI], 0.21-0.89). Women with pronounced asymmetry were less likely to be certain about their surgical decision (OR, 0.36; 95% CI, 0.21-0.60) and to believe that they were prepared to make the decision for surgery (OR, 0.25; 95% CI, 0.14-0.43). Increasing breast asymmetry was associated with higher surgeon distrust scores (2.14 vs 2.30 vs 2.35; P= .04) and with the occurrence of postoperative complications (distrust score: 2.23 vs 2.35; P= .03). Reoperation after BCS was not associated with patient satisfaction or trust in providers. CONCLUSIONS: Esthetic result after BCS was associated more profoundly with aspects of satisfaction than either surgical therapy or the occurrence of postoperative complications. The current findings indicated that surgeons who care for patients with breast cancer should identify the women at an increased risk for breast asymmetry preoperatively to effectively address their expectations of treatment outcomes.     

Surgeons’ Recommendation is the Factor in Determining the Breast Cancer Surgery Procedures: an Experience from Rural Hospital in Thailand

Introduction: The majority of breast cancer patients in rural hospital in developing countries still warrant for totalmastectomy. Surgeon advice regard surgical procedure is one of the most important factors in decision making. Ourstudy aims to compare the rate of breast-conserving surgery (BCS), mastectomy (MT) and mastectomy with immediatebreast reconstruction (MTIBR) between the surgeons who offer only MT (group A) and who offer BCS MT and MTIBR(group B). Method: A retrospective cohort study was conducted at Ratchaburi hospital, Thailand from January 2010to April 2014. We categorized patients into 2 groups (group A and B). Univariated analysis was selected to determinethe factors that associated with the breast surgery procedures. Results: From January 2010 to April 2014, we recruited310 breast cancer patients, 221 patients (71.2%) were treated by surgeons in group A, 89 patients (28.7%) by surgeonsin group B. The choice of breast surgery is significantly different between 2 groups (P<0.001). In group A, 213 (96.3%)patient had MT and only 3 (1.3%) BCS and 5 (2.2%) MTIBR. Whilst in group B, 58 (65.1%) patient had MT and11 (12.3%) BCS and 20(22.4%) MTIBR. Choice of breast surgery in patients with stage 1,2,3 are significantly differentbetween 2 groups (P=0.004, <0.001, 0.025 respectively). Age is the only factor that significantly affects the choiceof surgery in the group B but not in group A. Conclusion: Surgeon’s competency and comprehensive preoperativeconsultation by offering BCS, MT and MTIBR can affect the choice of surgical procedure for breast cancer patient.     

The use of the saddle prosthesis for reconstruction of the hip joint after tumor resection of the pelvis.

Reconstruction of the hip joint by a saddle prosthesis after excision of a malignant pelvic tumor is a relatively new method, which thus far has been mainly used for revision of infected hip arthroplasties. One patient with a metastatic cystosarcoma phyllodes and one patient with a chondrosarcoma of the pelvis were treated by local resection and reconstruction with a saddle prosthesis. Although the patient with the metastatic cystosarcoma phyllodes died 9 months after surgery due to metastatic disease, both patients had early recovery, with no difference in leg length and obtained early painless complete weight bearing with satisfactory functional result. These two case reports clearly illustrate the usefulness of the saddle prostheses in limb saving surgery for malignant tumors of the pelvis.     

Patient and provider characteristics that affect the use of axillary dissection in older women with stage I-II breast carcinoma

BACKGROUND: Axillary dissection for the evaluation and treatment of patients with breast carcinoma often is not performed in older women. The objective of this study was to examine patient, clinical, and surgeon characteristics associated with the use of axillary dissection after breast-conserving surgery (BCS). METHODS: A cohort of 464 women age > or = 67 years who were newly diagnosed with Stage I-II breast carcinoma and who underwent BCS were surveyed along with their 158 surgeons, and their medical records were reviewed. Patient, tumor, and provider characteristics were examined for association with the omission of axillary dissection. RESULTS: The majority of women (63.4%) underwent axillary lymph node dissection after BCS. Increasing age was associated strongly with decreasing odds of undergoing axillary lymph node dissection, even after considering patient health and preferences, clinical factors, and provider factors (odds ratio [OR], 0.11; 95% confidence interval [95%CI], 0.05-0.27). Independent of age and other factors, women in the lowest quartile of physical functioning were 37% less likely to undergo axillary lymph node dissection compared with women in the highest quartile (OR, 0.63; 95%CI, 0.62-0.64). Patients who were cared for by surgeons with subspecialty training in oncology were 60% less likely to undergo axillary lymph node dissection compared with patients who were cared for by other surgeons, even after considering other factors (OR, 0.41; 95%CI, 0.25-0.68). CONCLUSIONS: The results of this study demonstrated a correlation between lower use of axillary dissection and advancing age, lower functional status, and greater surgeon training. These findings suggest that simple, age-based considerations are important but are not the sole determinants of variations in treatment.     

Basic geriatric principles for colorectal surgeons: How to optimize assessment and care of older patients in the perioperative period

BackgroundThe majority of patients with colorectal cancer are older. For surgeons dealing with older patients, it is important to recognize patients that are frail and have an increased risk of complications and mortality. In this review, we will go through pre-treatment assessment, peri-operative management, as well as discharge planning and rehabilitation.MethodsThis review is based on searching the literature for studies regarding colorectal cancer, frailty, cognition, patient preferences and geriatric assessment as well as the academic and clinical experience of the authors.ResultsIn the pre-treatment assessment, surgeons need to consider capacity to consent, patient preferences, frailty and life-expectancy, risk of complications, and whether the patient can be optimized before surgery. Then, the patient and treatment options should be discussed at a multidisciplinary team meeting. When the patient is admitted for surgery, discharge planning should start immediately, and if complications such as delirium or falls occur, the patient should be co-managed with geriatric services.ConclusionFrail older adults with colorectal cancer need a tailored approach from pre-treatment assessment until discharge after surgery, and co-management with a geriatrician is recommended. If this is not possible, surgeons treating frail older patients may improve care by adapting some geriatric principles.     

The role of transanal total mesorectal excision

At inception, transanal total mesorectal excision (TaTME) was hypothesized to be a solution for several problems encountered in pelvic surgery, particularly for distal rectal cancer. The transanal part of the procedure is less hampered by patient related factors such as visceral obesity and a narrow bony pelvis and can thus overcome access and visualization problems encountered with a pure abdominal approach. Clearly, as for any new technique, a learning curve needs to be negotiated, ideally without unacceptable harm to patients. In experienced hands, TaTME might overcome challenges found in anatomically challenging rectal cancer patients as well as for other indications. The role of TaTME is not to replace, but rather complement its abdominal counterpart.     

结直肠外科术式历程——从经典到创新的演变

结直肠手术起源于早期文明，其演变遵循一定的规律，大多数外科技术都有其历史基础，从未脱离社会、手术平台和外科理念的进步。由于结直肠外科的发展与外科手术平台及手术理念的发展相互促进，本文对结直肠相关的历史资料进行收集，结合外科手术平台和理念的发展，从古埃及文化到现代文明对结直肠外科进行了历史回顾，阐述了结直肠外科手术演变。理解过去才能看到未来，对于结直肠外科医生尤其如是，正确认识结直肠手术演变是了解结直肠术式发展的最佳方式。     

Assessing the effect of a hands-on oncoplastic surgery training course: A survey of Canadian surgeons

BackgroundThe adoption of oncoplastic surgery in North America is poor despite evidence supporting the benefits. Surgeons take courses to acquire oncoplastic techniques, however, the effect of these courses is unknown. This study aimed to assess the impact of a hands-on oncoplastic course on surgeons’ comfort with oncoplastic techniques and rate of adoption of these techniques in their practice.Material and methodsAn online 10-question survey was developed and distributed to surgeons who had participated in a hands-on oncoplastic course offered in Ontario, Canada. Categorical data were reported using frequencies and percentages.ResultsA total of 105 surveys were sent out of which 69 attending surgeons responded (response rate: 65.7%). All respondents stated cosmesis was of the utmost importance in breast conserving surgery. The most common oncoplastic techniques they currently use included glandular re-approximation (98.4%), undermining of skin (93.6%), undermining of the nipple areolar complex (63.4%), and de-epithelialization and repositioning of the nipple areola complex (49.2%). Only 26% of respondnets stated they used more advanced techniques such as mammoplasty. Sixty percent of surgeons reported they used oncoplastic techniques in at least half of their cases. Ninety-two percent of respondents stated that the hands-on course increased the amount of oncoplastic techniques in their practice. At least 70% of respondents stated they would do another hands-on course. The main factor that facilitated the uptake of oncoplastic techniques was a better understanding of surgical techniques and planning.ConclusionA hands-on oncoplastic course helps surgeons adopt oncoplastic surgery techniques into their clinical practice. This teaching model allows surgeons to become comfortable with a variety of techniques. This study supports the relevance of a hands-on oncoplastic course to enhance the availability of safe oncoplastic surgery for breast cancer patients.     

Acute plain anterioposterior radiograph of the pelvis is not useful in detecting fractures of iliac wing and os sacrum: A prospective study of 73 patients using CT as gold standard

Conflicting opinions exist to what extent interpreters of an acute anterioposterior (AP) radiograph of the pelvis underdiagnose pelvic injury. We have prospectively evaluated the usefulness of a plain AP radiograph of the pelvis in detecting injuries, using CT as the gold standard. Seventy‐three haemodynamically stable blunt trauma patients, who had an AP radiograph of the pelvis and an abdominopelvic CT as part of their initial imaging evaluation, were included. There were 14 women and 59 men, with a mean age of 30 (3–61) years. Two senior radiologists, with special interest in CT examinations evaluating trauma, reviewed the radiographs and a month later the CT scans, blinded and independently. Usefulness index of the plain AP radiograph of the pelvis in detecting specific injuries was calculated using CT as the gold standard. A radiograph is regarded as useful if the usefulness index is 0.35 or more. The usefulness index for a plain AP radiograph of the pelvis for detecting a fracture of iliac wing and os sacrum was 0.25 and 0.01, respectively. An acute AP radiograph of the pelvis is not useful in detecting a fracture of iliac wing or os sacrum.     

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a review of factors contributing to morbidity and mortality

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with prolonged survival for appropriately selected patients with peritoneal dissemination of abdominal malignancies. CRS and HIPEC has been criticized for perceived high rates of morbidity and mortality. Morbidity and mortality rates of CRS and HIPEC, however, do not appear dissimilar to those of other large abdominal surgeries, particularly when relevant patient and operative factors are accounted for. The risk of morbidity and mortality following this surgery for a given individual can be predicted in part by a variety of patient and operative factors. While strong data are lacking, the limited data that exists on the matter suggests that the independent contribution of the heated intraperitoneal chemotherapy to CRS and HIPEC morbidity is relatively small. A more thorough understanding of the patient and operative factors associated with CRS and HIPEC morbidity and mortality, as well as the specific complications related to the intraperitoneal chemotherapy, can better inform clinicians in multidisciplinary teams and patients alike in the decision-making for this surgery.     

Navigationsgestützte Resektion maligner Knochentumoren des Beckens

The use of computer-navigated surgery aims at increasing the accuracy with which operations can be performed. New fields of applications are the preoperative planning, registration and 3-dimensional observation of osteotomies for resections of malignant pelvic bone tumors in orthopedic surgery. The basic setup includes preoperatively obtained 3-dimensional images of the pelvis by computed tomography and a navigation system with computer hardware, tracking system and software for intraoperative matching and visualization. Necessary intraoperative matching of the position and orientation of the preoperatively obtained 3-dimensional image of the pelvis with the position and orientation of the patient’s bony anatomy being operated must be performed before the preoperatively defined osteotomy levels can be identified. The osteotomies are done with tracked surgical chisels. The advantages of the tracked surgical instruments are 3-dimensional observation of the osteotomies in real time and the permanent correction of every intraoperative movement of the patient in real time. With postoperatively obtained computed tomography images, the accuracy of the osteotomies can be standardized compared with the preoperative images and defined osteotomies. We think that computer-navigated resection of malignant pelvic tumors can be helpful in increasing the accuracy of the osteotomies, to realize adequate margins, and to optimize the functional outcome.     

Conversations for providers caring for patients with rectal cancer: Comparison of long‐term patient‐centered outcomes for patients with low rectal cancer facing ostomy or sphincter‐sparing surgery

For some patients with low rectal cancer, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter‐sparing surgery. Sphincter‐sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients who are eligible for sphincter‐sparing surgery may not be well served by the surgery, and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries or to help physicians elicit long‐term surgical outcomes. Furthermore, comparison of long‐term outcomes and late effects after the two surgeries has not been synthesized. Therefore, this systematic review summarizes controlled studies that compared long‐term survivorship outcomes between these two surgical groups. The goals are: 1) to improve understanding and shared decision‐making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) to increase the patient's participation in the decision; 3) to alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, to improve patients' long‐term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter‐sparing surgery as well as questions to ask during follow‐up examinations to ascertain any long‐term challenges facing the patient. CA Cancer J Clin 2016;66:387–397. © 2016 American Cancer Society.     

Carcinosarcoma of the upper urinary tract with an aggressive angiosarcoma component

Carcinosarcomas (CS) are biphasic tumors with malignant epithelial and mesenchymal elements. The sarcomatoid elements of CS can include chondrosarcoma, malignant fibrous histiocytoma, osteosarcoma, leiomyosarcoma, fibrosarcoma, or liposarcoma. CS of the upper urinary tract are extremely rare but are associated with a poor prognosis. We report a case of a 44-year-old man with a localized right renal pelvis mass treated with a right nephroureterectomy. The pathological examination showed a high-grade urothelial carcinoma of the renal pelvis, stage III (pT3aNxM0). A few days later, he developed lower back pain, hematuria, cough with hemoptoic sputum and progressive dyspnea. Radiological explorations showed multiple bilateral lung nodules and a retroperitoneal mass. A CT-guided biopsy of the retroperitoneal mass revealed a high-grade angiosarcoma. A review of the nephrectomy specimen showed a microscopic focus of angiosarcoma in the urothelial carcinoma. Therefore, the initial diagnosis was changed to CS of the renal pelvis with an angiosarcoma component. The patient developed progressive respiratory failure and died 8 weeks after surgery. An autopsy revealed a large retroperitoneal mass with metastatic nodules to the abdominal wall, diaphragm, small intestine, liver, spleen, and lung. All lesions were angiosarcoma, with no evidence of urothelial carcinoma. This is the first case reported of a patient with CS of the upper urinary tract with an angiosarcoma component with a very aggressive course that caused the immediate appearance of multiple angiosarcoma metastases. We also describe the clinical and molecular characteristics of CS, which will help to contribute to a better understanding of this type of tumor.