A Comparative Validation of Primary Surgical Versus Post-neo-adjuvant Chemotherapy Sentinel Lymph Node Biopsy for Stage III Breast Cancers

Introduction

Sentinel lymph node biopsy (SLNB) is the standard of care for staging N0 primary early breast cancers (EBC). Patients in developing countries mostly present with large (LOBC) or locally advanced cancers (LABC) and are treated with neo-adjuvant chemotherapy (NACT). Accuracy of SLNB in staging stage III N0 and post-NACT N0 patients is uncertain. This prospective validation study on LOBC/LABC patients compared the accuracy of SLNB between primary versus post-NACT surgery.

Materials and methods

Fifty T3/T4, N0 patients undergoing primary surgery (Group I) and 70 LOBC/LABC (index stage) treated with NACT and N0 at the time of surgery (Group II) were inducted. Validation SLNB was performed using low-cost methylene-blue and ^99mTc-Antimony colloid. SLN identification (IR) and false-negative (FNR) rates were compared between the groups. Sub-group analysis was done in Group II per index tumor and nodal stage to identify factors predicting SLN IR and FNR in post-NACT patients. SLN IR and FNR in both groups were compared with those in previously published SLN validation study and meta-analysis in EBC.

Results

Using combination of blue-dye and radio-colloid, post-NACT SLN IR and FNR (82.9, 13.5 %) were far inferior to T3/T4 primary surgery group (94, 7.7 %; p values 0.034, 0.041) and in EBC. SLN IR using blue-dye alone was dismally low in post-NACT LABCs. Factors predicting unidentified post-NACT SLN and false-negative SLNB included young age, LVI, skin infiltration, extra-nodal spread or N2a stage, and UOQ tumors.

Conclusions

Accuracy of SLNB in T3, N0 tumors undergoing primary surgery is comparable to that of SLNB for N0 EBC. In post-NACT patients, SLNB IR are lower and FNR are higher. Factors predictive of non-identification and false-negative SLNB include pre-NACT skin involvement (T4b), N2a stage or extra-nodal invasion and LVI, and to a lesser extent, young age and UOQ location of the tumor.

     

Inter-facility Transfer of Surgical Emergencies in a Developing Country: Effects on Management and Surgical Outcomes

Objectives

Outcomes of surgical emergencies are associated with promptness of the appropriate surgical intervention. However, delayed presentation of surgical patients is common in most developing countries. Delays commonly occur due to transfer of patients between facilities. The aim of the present study was to assess the effect of delays in treatment caused by inter-facility transfers of patients presenting with surgical emergencies as measured by objective and subjective parameters.

Methods

We prospectively collected data on all patients presenting with an acute surgical emergency at Aga Khan University Hospital (AKUH). Information regarding demographics, social class, reason and number of transfers, and distance traveled were collected. Patients were categorized into two groups, those transferred to AKUH from another facility (transferred) and direct arrivals (non-transfers). Differences between presenting physiological parameters, vital statistics, and management were tested between the two groups by the chi square and t tests.

Results

Ninety-nine patients were included, 49 (49.5 %) patients having been transferred from another facility. The most common reason for transfer was “lack of satisfactory surgical care.” There were significant differences in presenting pulse, oxygen saturation, respiratory rate, fluid for resuscitation, glasgow coma scale, and revised trauma score (all p values <0.001) between transferred and non-transferred patients. In 56 patients there was a further delay in admission, and the most common reason was bed availability, followed by financial constraints. Three patients were shifted out of the hospital due to lack of ventilator, and 14 patients left against medical advice due to financial limitations. One patient died.

Conclusions

Inter-facility transfer of patients with surgical emergencies is common. These patients arrive with deranged physiology which requires complex and prolonged hospital care. Patients who cannot afford treatment are most vulnerable to transfers and delays.     

Comparative Study of Surgical Margins in Oncoplastic Surgery and Quadrantectomy in Breast Cancer

Background Oncoplastic surgery for breast cancer is a novel concept that combines a plastic surgical procedure with breast-conserving treatment to improve the final cosmetic results. The aim of this study was to evaluate the oncological safety of oncoplastic procedures by studying the status of the surgical margins of the excised tumor specimen in comparison with standard quadrantectomies.Methods Thirty consecutive breast cancer patients undergoing oncoplastic surgery (group 1) and 30 patients undergoing standard quadrantectomy (group 2) were prospectively studied with regard to the stage of breast cancer, the surgical procedures performed, the volume of breast tissue excised, and the histopathology of the tumor specimen, with specific details on surgical margins.Results Patients who underwent oncoplastic surgery (group 1) were younger (mean age, 48.73 years) than patients who had a classic quadrantectomy (group 2; mean age, 55.76 years; P = .022). The mean volume of the excised specimen in group 1 was 200.18 cm³, compared with 117.55 cm³ in group 2 (P = .016). Surgical margins were negative in 25 cases out of 30 in group 1 and 17 out of 30 in group 2 (P = .05). The average length of the surgical margin was 8.5 mm in group 1 and 6.5 mm in group 2, but the difference was not statistically significant (P = .074).Conclusions Oncoplastic surgery adds to the oncological safety of breast-conserving treatment because a larger volume of breast tissue can be excised and a wider negative margin can be obtained. It is especially indicated for large tumors, for which standard breast-conserving treatment has a high probability of leaving positive margins.     

Breast Conservation: Evolution of Surgical Strategies

Abstract:   The surgical strategy for breast cancer has changed considerably over the last decade. Breast-conserving therapy (BCT) is now standard treatment. Today, at least three out of four breast cancer patients are, in principle, eligible for BCT. However, several specific factors must be considered to choose the correct surgical strategy. This review provides a scientific overview of the history, surgical methodology, and specific aspects of BCT.      

Undergraduate Surgery Clerkship and the Choice of Surgery as a Career: Perspective from a Developing Country

Background

There are concerns regarding a possible decline in the proportion of students choosing surgery as a career in some countries in sub-Saharan Africa. Published works indicate that most students choose their ultimate career during undergraduate training. The present study was undertaken to assess the medical student’s perception of the surgery clerkship and determine its influence in the choice of surgery as a career.

Methods

The study involved a cross-sectional survey of 2009 and 2010 graduating medical classes of the University of Nigeria based on self-administered questionnaires. The clerkship evaluation was assessed on a 3-point Likert scale (1 = poor; 3 = excellent).

Results

The response rate was 70.3 % (275/391); 179 (65.1 %) of the students were males and 96 (34.9 %), females. Sixty-one (22.2 %) rated the overall quality of their surgery clerkship as excellent (mean rating = 2). Compared with the other three major clerkships, surgery has the lowest rating for overall quality (mean rating: surgery = 2; others = 2.2). Aspects of the clerkship experience that contributed to the overall lower rating of surgery include quality of opportunity to participate in direct patient care; clarity of posting goals and objectives; experience in learning history taking skills, basic physical examination skills, and interpretation of laboratory data; accessibility of faculty; and students’ perception that they were treated in a respectful manner. The major suggestions to improve clerkship quality were these: (1) more involvement in direct patient care (n = 154; 56 %), and (2) improvement in student–faculty interaction (n = 9 1; 33.1 %). Overall, 96 (34.9 %) students selected surgery as a specialty, and 39.3 % (108/275) selected the other three major specialties. Surgery was selected by 17/48 (35.4 %), 59/166 (35.5 %), and 20/61 (32.8 %) students who rated the surgery clerkship as “poor,” “just right,” and “excellent,” respectively (p = 0.876). Factors indicated as major influences in the choice of surgical specialty included personal satisfaction 41.7 % (40/96), clerkship experience 36.4 % (35/96), and diligence of faculty 13.5 % (13/96).

Conclusions

Periodic assessment of the satisfaction of medical students regarding their surgical clerkship experience is important. In our setting, we have identified aspects of the surgical clerkship that could be improved to enhance the quality of the experience, ensure the attractiveness of the field to the most qualified candidates, and boost interest in surgery as a career.     

Pancreaticoduodenal Resection for Malignancy in a Low-volume Center: Long-term Outcomes from a Developing Country

Background

The technical complexity of pancreatic resection has made it a specialized procedure performed in high-volume centers. It has been shown that patients operated on in high-volume pancreatobiliary centers have fewer complications and better survival. The purpose of this study was to share our experience with and report long-term outcomes of pancreaticoduodenal resections performed in a low-volume center in Pakistan.

Methods

Data of patients who underwent pancreaticoduodenal resection for adenocarcinoma at our institute from 1999 to 2012 were reviewed. A total of 39 patients were included in the study. Variables included patients’ clinical and histopathological characteristics. Outcome was determined based on complication rate, 30- and 90-day mortality, disease-free survival, and overall survival. For survival analysis, Kaplan–Meier curves were used and significance was determined using a log rank test. Univariate Cox analysis was performed to determine significant factors for multivariate analysis.

Results

The majority of tumors [20 (51 %)] were moderate grade, T1/T2 [20 (51 %)], ampullary adenocarcinomas [18 (46 %)]. Mean hospital stay was 14 ± 8 days. The mean number of nodes removed was 13.9 ± 6.9, while mean number of positive nodes was 1 ± 1.7. Expected 5-year overall survival and relapse-free survival were 38 and 48 %, respectively. Overall 5-year survival was significantly different with respect to nodal involvement, i.e., 47 vs. 28 % (P = 0.018). On univariate analysis, nodal involvement was the only factor associated with an increased risk of death (P = 0.02, hazard ratio [HR] 2.9, confidence interval [CI] 1.1–7.8).

Conclusion

Low-volume centers are an acceptable alternate to high-volume centers for performing pancreaticoduodenal resection in carefully selected patients. Efforts should be directed at developing specialized hepatobiliary centers in developing countries.     

Complications Post Abdominoplasty After Surgical Versus Non-surgical Massive Weight Loss: a Comparative Study

Purpose

This study aims to investigate the rate of short- and long-term complications as well as the need for operative revisions after abdominoplasty for patients following surgical versus non-surgical weight loss methods.

Methods

This is a retrospective chart review that enrolled consecutive patients undergoing abdominoplasty across a 5-year period, aged 18 years and above, opting for abdominoplasty after weight loss achieved through bariatric surgery or diet and exercise alone.

Results

A total of 364 patients lost weight through bariatric surgery and 106 by diet and exercise alone. There were no significant differences in comorbidity status, but past body mass index (BMI) was higher for the surgical weight loss (SW) group (47.6 ± 10.2 and 40.4 ± 8.6, respectively; p value < 0.0001). Percent excess weight loss (EWL) was 68 ± 14.5 for the SW group and 55.7 ± 19.4 for the NSW group, p value < 0.0001. Pre- and postoperative blood hemoglobin levels were significantly lower in the SW group (p < 0.05). Neither short-term complications (thromboembolic events, wound complications, or infections) nor long-term complications (umbilical deformity, delayed wound healing, or infection) and operative revisions were significantly different across both groups (p > .05).

Conclusion

Bariatric surgery does not increase the risk of short- or long-term complications or the need for operative revision after abdominoplasty.

Graphical abstract

     

Long-Term Outcomes After Laparoscopic Surgery Versus Open Surgery for Rectal Cancer: A Propensity Score Analysis

Background

The aim of this study was to compare the long-term outcomes of laparoscopy-assisted surgery (LAP) with those for open surgery (OS) when excising nonmetastatic rectal cancers.

Methods

We reviewed the prospectively collected records of all patients (n = 1,009) undergoing OS or LAP from January 2000 to November 2008 at Kyungpook National University Hospital. We undertook propensity score analyses and compared outcomes for the OS and LAC groups in a 1:1 matched cohort. Covariates in the model for propensity scores included age, gender, preoperative tumor marker level, preoperative chemoradiation status, tumor height from the anal verge, and clinical tumor stage. Subgroup analysis was conducted to evaluate the oncologic safety of LAP in patients with extraperitoneal rectal cancers.

Results

There were no significant differences in mortality, morbidity, and pathological quality in the propensity-matched cohort (n = 812). The combined 3-year local recurrence rate for all tumor stages was 3.8 % (95 % confidence intervals [95 % CI], 1.9–5.7 %) in the LAP group and 5.9 % (95 % CI, 3.9–8.3 %) in the OS group (P = .089 by log-rank test). The combined 3-year disease-free survival for all stages was 80.5 % (95 % CI, 76.6–84.4 %) in the LAP group and 82.9 % (95 % CI 79.2–86.6 %) in the OS group (P = .516 by log-rank test). Similar results were confirmed for the subgroup of patients with extraperitoneal rectal cancers.

Conclusions

Laparoscopic rectal excision for rectal cancer is feasible and safe with acceptable oncologic outcomes. Further prospective multicenter trials are warranted before incorporating this technology into routine surgical care.     

Post-Neoadjuvant Gemcitabine and Cisplatin with Regional Hyperthermia for Patients with Triple-Negative Breast Cancer and Non-pCR after Neoadjuvant Chemotherapy: A Single-Institute Experience

BackgroundPatients with triple-negative primary breast cancer (TNBC) who have residual invasive carcinoma after neoadjuvant chemotherapy have poor prognosis. Proven adjuvant approaches to reduce the risk of recurrence and improve outcome in patients with non-pathological complete response (non-pCR) are limited.MethodsFrom our institutional registry, a consecutive case series of patients with operable, unilateral, primary invasive noninflammatory early TNBC of stage I-IIIB and pathologically verified residual cancer cells (no pathological complete response) after neoadjuvant chemotherapy underwent adjuvant treatment with gemcitabine plus cisplatin combined with regional hyperthermia. For quality assurance, we analyzed feasibility, efficacy, and toxicity of all treated patients. Outcome was evaluated for the entire group of patients as well as for the subgroups of patients with or without lymph node involvement at baseline (cN0/ cN+).ResultsFrom August 2012 to January 2019, we offered this treatment to 53 patients at our center as part of routine care. The median follow-up was 38 months. The majority of patients (64.2%) had cT2 tumors at baseline. Twenty-four patients (45%) were clinically node positive as evaluated by sonography. Thirty-nine patients (74%) had grade 3, and 14 patients (26%) had grade 2 tumors. Forty-one patients (76%) showed a regression grade 1 according to Sinn. Patients received a median of six treatment cycles of gemcitabine and cisplatin (range 1–6) combined with 12 applications of regional hyperthermia (median 12, range 2–12). Disease-free survival (DFS) at 3 years was 57.5%. In patients with no lymph node involvement at baseline (cN0), DFS at 3 years was significantly higher than in initially node-positive (cN+) patients (80 vs. 31%; p = 0.001). Overall survival (OS) at 3 years was 81.6%. In patients with no lymph node involvement at baseline (cN0), OS at 3 years was significantly higher than in node-positive (cN+) patients (93 vs. 70.4%; p = 0.02). Overall, grade 3/4 toxicities were leukopenia (38%), thrombocytopenia (4%), and anemia (4%).ConclusionAfter standard neoadjuvant chemotherapy containing anthracycline plus cyclophosphamide followed by taxanes, addition of adjuvant gemcitabine plus cisplatin in combination with regional hyperthermia was safe and effective in TNBC patients with non-pCR.     

Medical or Surgical Therapy for Primary Aldosteronism: Post-treatment Follow-up as a Surrogate Measure of Comparative Outcomes

Background

In primary aldosteronism (PA), lateralized aldosterone excess can be treated with aldosterone antagonists or surgery, which raises the question as to whether surgery or medications should be the preferred management. A difference in required patient follow-up/clinic resource utilization might provide a surrogate estimate of the comparative outcome efficacy of medical versus surgical therapy.

Methods

From a retrospective review of our adrenal vein sampling (AVS) database June 2005 to August 2011, we chose all patients with PA who were surgical candidates and investigated with AVS. There were 77 subjects; 38 (with aldosteronoma) had unilateral adrenalectomy, and 39 (7 aldosteronoma and 32 hyperplasia) were treated with primary medical therapy. After AVS, patients with nonsurgical disease immediately started mineralocorticoid antagonists and follow-up measured from the AVS date. Surgical patients were seen in the clinic immediately after hospital discharge and follow-up measured from the operative date. Target BP was <140/90 before discharge to the community.

Results

Total follow-up ranged from 1 to 55 months, and 4 subjects were lost to follow-up. Mean follow-up in the medical and surgical groups was 13.4 versus 6.5 months (p < 0.004). There was a trend toward more clinic visits for the medical group (7.0 vs 5.2, p = 0.17).

Conclusions

Most PA patients can be managed by medical or surgical approaches. Medically treated patients require much longer-term follow-up to manage their condition, whereas most surgical patients can be successfully discharged shortly after surgery. When possible, surgical management may represent a more expeditious means of treating PA.     

Surgical Management of Haemophilic Pseudotumors: Experience in a Developing Country

Aim: Hemophilic pseudotumors result from repeated episodes of bleeding into bone, subperiosteum, and soft tissue. Since clotting factors became available, uncontrolled perioperative bleeding is a less significant problem for surgeons in developed countries. However, they are more difficult to come by in China. Additionally, patients often have to undergo surgery for giant masses and suffer complications. We wanted to present our experience in the surgical management of hemophilic pseudotumors over a 40-year period. Methods: We retrospectively reviewed 429 hemorrhagic coagulopathy patients between 1983 and 2015. Diagnosis of hemophilic pseudotumor was confirmed following clinical, radiological, and pathological criteria. The data were recorded and analyzed: type and severity of hemophilia, presence of inhibitor, etiological antecedent, localization of pseudotumors, clinical signs, surgical management and outcomes. Results: Eighteen pseudotumor patients underwent surgical treatment. All of them were male, with mean age of 34.3 years. Fifteen patients had hemophilia A and three patients had hemophilia B. There were twelve proximal and two distal pseudotumor patients. The mean follow-up was 51.9 months. For pseudotumors in the extremities, complete surgical resection was achieved. For four patients with pelvic or abdominal pseudotumors, complete surgical resection was only achieved in two patients because of preventing potential vital organs injuries. Delayed healing of the incision, allergic reactions, and ureteral injury were the major complications. Conclusion: Surgery is an alternative method with safety and efficacy. Careful and individual treatment is required by the hematologist, orthopedic surgeon and other members of the team who collaborate and participate in hemophilic surgery.     

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis: Outcomes from a Single Tertiary Institution

Background

Cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC) is an effective but morbid procedure in the treatment of peritoneal carcinomatosis. We report our outcomes at a single tertiary institution.

Method

A total of 170 consecutive patients underwent CRS-HIPEC for peritoneal carcinomatosis between July 2007 and August 2012. The peritoneal cancer index (1–39) was used for peritoneal carcinomatosis (PC) staging. Mitomycin C (88.8 %) was administered intraperitoneally at 42 °C for 90 mins. Risk factors associated with major morbidities were analyzed. The Kaplan-Meier method was used for survival analyses.

Results

The mean age was 55.1 (±11.3) years, and the majority (77.1 %) of patients had complete cytoreduction (CC0-1). Tumor types included colorectal (n?=?51, 30.0 %), appendiceal (n?=?50, 29.4 %), pseudomyxoma peritonei (n?=?16, 9.4 %), and other (n?=?53, 31.2 %). Factors associated with major complications were estimated blood loss (>400 ml), length of stay (>1 week), intraoperative blood transfusion, operative time (>6 h), and bowel anastomosis. Intraoperative blood transfusion was the only independent prognostic factor on multivariate analysis (p?=?0.031). Median follow-up was 15.7 months (±1.2). The recurrence rates for colorectal and appendiceal carcinoma at 1 and 3 years were 40 %, 53.5 % and 68 %, 79.1 %, respectively. The 1- and 3-year overall survival for colorectal and appendiceal carcinomatosis was 74.0 %, 32.5 % and 89.4 %, 29.3 %, respectively. Intraoperative peritoneal cancer index (PCI) score (>16) and need for blood transfusion were factors independently associated with poor survival (p?<?0.05).

Conclusion

Our single institution experience of CRS/HIPEC procedures for peritoneal carcinomatosis demonstrates acceptable perioperative outcome and long-term survival. Optimal cytoreduction was achieved in the majority of cases. Intraoperative PCI?>?16 was associated with poor survival. This series supports the safety of CRS-HIPEC in selected patients.