Excessive resections in breast-conserving surgery: a retrospective multicentre study

The main determinant of cosmetic outcomes following breast-conserving surgery (BCS) for breast cancer is the volume of resection. The importance of achieving optimal oncological control may lead to an unnecessarily large resection of breast tissue. The aim of this study is to evaluate excess resection volume in BCS for cancer by determining a calculated resection ratio (CRR). This retrospective study was conducted in four affiliated institutions and involved 726 consecutive patients with T1-T2 invasive breast cancer treated by BCS between January 2006 and 2009. The pathology reports were reviewed for tumor palpability, tumor size, surgical specimen size, and oncological margin status. The optimal resection volume (ORV) was defined as the spherical tumor volume with an added 1.0 cm margin of healthy breast tissue. The total resection volume (TRV) was defined as the ellipsoid volume of the surgical specimen. CRR was determined by dividing the TRV by the ORV. Of all tumors, 72% (525/726) were palpable, and 28% (201/726) were nonpalpable. The tumor stage was T1 in 492 patients (67.8%) and T2 in 234 patients (32.2%). The median CRR was 2.5 (0.01-42.93). Margin status was positive or focally positive in 153 patients (21.1%). Lower tumor stage was associated with a higher CRR (factor 0.61 [p < 0.0001] and a lower positive margin rate [p = 0.064]). Accordingly, the median CRR of the nonpalpable lesions was higher than that of the palpable lesions (3.1 and 2.2, respectively; p < 0.01), and the involved margin rate was lower (17.4% and 22.5%, respectively; p = 0.13). Of patients with a CRR >4.0, 10.7% still had tumor involved margins. This study clearly shows that BCS is associated with excessive resection of healthy breast tissue while clear margins are not assured. Surgical factors should be modified to improve surgical accuracy.     

Is major liver surgery associated with an increased systemic inflammatory response? A prospective comparison of hemihepatectomy and other major abdominal surgery

Abstract: Aims/Background: Extensive liver resection is associated with a higher morbidity and mortality than other major abdominal surgery. Because the liver is responsible for the clearance of pathogenic particles as well as the clearance and degradation of several inflammatory mediators, the high rate of complications after liver surgery may be due to an enhanced or prolonged inflammatory response. The objective of this prospective study was to investigate whether major liver resection is associated with an enhanced systemic inflammatory response. Methods: The course of various inflammatory parameters was studied in 12 patients undergoing a hemihepatectomy and the results were compared with those of 12 patients undergoing other major abdominal surgery. Results: After hemihepatectomy, the plasma levels of IL-6, IL-8, sPLA₂ and elastase were similar to the levels after other major abdominal surgery, though the hepatectomized patients showed higher levels of lactoferrin, possibly due to impaired hepatic clearance. In addition, the hemihepatectomized patients showed signs of impaired liver function, as was indicated by increased plasma bilirubin and ASAT levels, whereas the other patients did not. Conclusions: The inflammatory response associated with major liver resection is not significantly different from that after other major abdominal surgery, and therefore does not explain the increased complication rate that is seen after major liver resection. We infer that the most important factor in the development of complications after liver resection may be the hepatic failure itself.     

Spectrum of Fusarium infections in tropical dermatology evidenced by multilocus sequencing typing diagnostics

Fusarium species are emerging causative agents of superficial, cutaneous and systemic human infections. In a study of the prevalence and genetic diversity of 464 fungal isolates from a dermatological ward in Thailand, 44 strains (9.5%) proved to belong to the genus Fusarium. Species identification was based on sequencing a portion of translation elongation factor 1‐alpha (tef1‐α), rDNA internal transcribed spacer and RNA‐dependent polymerase subunit II (rpb2). Our results revealed that 37 isolates (84%) belonged to the Fusarium solani species complex (FSSC), one strain matched with Fusarium oxysporum (FOSC) complex 33, while six others belonged to the Fusarium incarnatum‐equiseti species complex. Within the FSSC two predominant clusters represented Fusarium falciforme and recently described F. keratoplasticum. No gender differences in susceptibility to Fusarium were noted, but infections on the right side of the body prevailed. Eighty‐nine per cent of the Fusarium isolates were involved in onychomycosis, while the remaining ones caused paronychia or severe tinea pedis. Comparing literature data, superficial infections by FSSC appear to be prevalent in Asia and Latin America, whereas FOSC is more common in Europe. The available data suggest that Fusarium is a common opportunistic human pathogens in tropical areas and has significant genetic variation worldwide.     

Management of recurrent rectal cancer： A population based study in greater Amsterdam

AIM： To analyze, retrospectively in a populationbased study, the management and survival of patients with recurrent rectal cancer initially treated with a macroscopically radical resection obtained with total mesorectal excision （TME）.
METHODS： All rectal carcinomas diagnosed during 1998 to 2000 and initially treated with a macroscopically radical resection （632 patients） were selected from the Amsterdam Cancer Registry. For patients with recurrent disease, information on treatment of the recurrence was collected from the medical records.
RESULTS： Local recurrence with or without clinically apparent distant dissemination occurred in 62 patients （10%）. Thirty-two patients had an isolated local recurrence. Ten of these 32 patients （31%） underwent radical re-resection and experienced the highest survival （three quarters survived for at least 3 years）. Eight patients （25%） underwent non-radical surgery （median survival 24 rno）, seven patients （22%） were treated with radio- and/or chemotherapy without surgery （median survival 15 mo） and seven patients （22%） only received best supportive care （median survival 5 too）. Distant dissemination occurred in 124 patients （20%） of whom 30 patients also had a local recurrence. The majority （54%） of these patients were treated with radio- and/or chemotherapy without surgery （median survival 15 mo）. Twenty-seven percent of these patients only received best supportive care （median survival 6 mo）, while 16% underwent surgery for their recurrence. Survival was best in the latter group （median survival 32 mo）.
CONCLUSION： Although treatment options and survival are limited in case of recurrent rectal cancer after radical local resection obtained with TME, patients can benefit from additional treatment, especially if a radical resection is feasible.     

Name Changes in Medically Important Fungi and Their Implications for Clinical Practice

Recent changes in the Fungal Code of Nomenclature and developments in molecular phylogeny are about to lead to dramatic changes in the naming of medically important molds and yeasts. In this article, we present a widely supported and simple proposal to prevent unnecessary nomenclatural instability.     

Occurrence of Ochroconis and Verruconis Species in Clinical Specimens from the United States

Ochroconis is a dematiaceous fungus able to infect immunocompetent people. Recently, the taxonomy of the genus has been reevaluated, and the most relevant species, Ochroconis gallopava, was transferred to the new genus Verruconis. Due to the important clinical implications of these fungi and based on the recent classification, it was of interest to know the spectra of Ochroconis and Verruconis species in clinical samples received in a reference laboratory in the United States. A set of 51 isolates was identified morphologically and molecularly based on sequence analyses of the nuclear ribosomal RNA (nrRNA), actin, and β-tubulin genes. Verruconis gallopava was the most common species (68.6%), followed by Ochroconis mirabilis (21.5%). One isolate of Ochroconis cordanae was found, being reported for the first time in a clinical setting. The most common anatomical site of isolation was the lower respiratory tract (58.8%), followed by superficial and deep tissues at similar frequencies (21.6 and 19.6%, respectively). Interestingly, three new species were found, which are Ochroconis olivacea and Ochroconis ramosa from clinical specimens and Ochroconis icarus of an environmental origin. The in vitro antifungal susceptibilities of eight antifungal drugs against the Ochroconis isolates revealed that terbinafine and micafungin were the most active drugs.