A modified sentinel node and occult lesion localization (SNOLL) technique in non-palpable breast cancer. A pilot study

Background: The spread of mammographic screening programs has allowed an increasing amount of early breast cancer diagnosis. A modern approach to non-palpable breast lesions requires an accurate intraoperative localization, in order to achieve a complete surgical resection. In addiction, the assessment of lymph node status is mandatory as it represents a major prognostic factor in these patients. The aim of this study is to evaluate the reliability of a modified technical approach using a single nanocolloidal radiotracer to localize both sentinel node and breast occult lesion. Methods: Twenty-five patients with a single non-palpable breast lesions and clinically negative axilla were enrolled. In the same day of surgery, patients underwent intratumoral and peritumoral administration of 99mTc-labeled nanocolloid tracer under sonographic guidance. A lymphoscintigraphy was performed to localize the sentinel lymph node and its cutaneous projection was marked on the skin in order to guide the surgeon to an optimal incision. During surgery an hand-held gamma-detection probe was used to select the best surgical access route and to guide localization of both occult breast lesion and sentinel lymph node. After specimen excision, the surgical field was checked with the gamma-probe to verify the absence of residual sources of significant radioactivity, thereby ensuring a radical treatment in a single surgical session and minimizing normal tissue excision. Results: Both targeted breast lesion and sentinel lymph node were localized and removed at the first attempt in every patients and histopathological diagnosis of malignancy was confirmed in 25/26 samples. Non-palpable lesions were included within the surgical margins in all patients and in all samples surgical margins were free from neoplastic infiltration thus avoiding any further reintervention. Only two patients showed metastatic involvement of sentinel lymph node. Conclusions: The modified sentinel node and occult lesion localization (SNOLL) technique performed with a single injection of nanocolloidal radiotracer has shown an excellent intraoperative identification rate of both non-palpable lesion and sentinel lymph node. This procedure offers, as opposed to standard techniques, an accurate, simple and reliable approach to the management of non-palpable breast cancer

Mandatory multidisciplinary approach for the evaluation of the lymph node status in rectal cancer

Colorectal cancer is the third most frequently reported malignancy and also the third leading cancer-related cause of death worldwide. Lymph node evaluation, both preoperatively and postoperatively, represents an important aspect of the diagnosis and therapeutic strategy in colorectal cancer, such that an accurate preoperative staging is required for a correct therapeutic strategy. Treatment of rectal cancer with positive lymph nodes, a very important predictive prognostic parameter, is currently based on neoadjuvant chemoradiotherapy followed by total/ surgical mesorectal excision and adjuvant regimen. Preoperative evaluation of the lymph node status in rectal cancer is based on endoscopic ultrasound and magnetic resonance imaging, but their accuracy, specificity, and sensitivity still require improvement. Postoperative evaluation also presents points of debate, especially related to the role of sentinel lymph node mapping and their final implication, represented by detection of micrometastases and isolated tumor cells. The pathologic interpretation of tumor deposits represents other points in discussion. From a surgical perspective, extended lateral lymph node dissection vs. abstinence and (neo)adjuvant therapeutic approach represent another unresolved issue. This review presents the major controversies existing today in the treatment and pathologic interpretation of the lymph nodes in rectal cancer, the role/ indication and value of the lateral pelvic lymph node dissection, and the postoperative interpretation of the value of the micrometastatic disease and tumor deposits

Histopathology report on colon cancer specimens; measuring surgical quality, an increasing stress for surgeons

Introduction. Improving the quality of surgical resections by evaluating surgical specimens is probably the most important feedback a surgeon can receive. Moreover, prognosis of patients with colon cancer is based on achieving appropriate resection margins and assessment of lymph node status. For these reasons we aim to provide a retrospective analysis on colon cancer specimens operated by a single surgical team. Materials and Methods. 88 patients operated between 2013 and 2016 were included in the study. Data were gathered prospectively and assessed by multivariate analysis for the main variables (age, gender, tumor staging, specimen length, distance to closest resection margin, number of lymph nodes, and number of positive lymph nodes). Results. The mean number of lymph nodes excised was 31,9, with more after right colectomies (39.6) than after left colonic resections (29.1). The average specimen length was 29.2cm after right colectomies, 35.6cm after left hemicolectomies and 18cm after segmental colectomies. There was a significant correlation between the number of lymph nodes, specimen length, and age of patients. Conclusion. Lymph node status is correlated with specimen length and age. The standard of 12 lymph nodes was achieved and surpassed, being comparable to the benchmark literature. Standards on colon resections need to be reevaluated as many surgeons are pressured by quality measurements which do not always reflect sound oncologic principles

Increased lymph node yield in colorectal cancer is not necessarily associated with a greater number of lymph node positive cancers

Peer reviewedPublisher PD

Ultrasound mapping of lymph node and subcutaneous metastases in patients with cutaneous melanoma: Results of a prospective multicenter study

Background: Ultrasound (sonography, B-mode sonography, ultrasonography) examination improves the sensitivity in more than 25% compared to the clinical palpation, especially after surgery on the regional lymph node area. Objective: To evaluate the distribution of metastases during follow-up in the draining lymph node areas from the scar of primary to regional lymph nodes ( head and neck, supraclavicular, axilla, infraclavicular, groin) in patients with cutaneous melanoma with or without sentinel lymph node biopsy (SLNB) or former elective or consecutive complete lymph node dissection in case of positive sentinel lymph node (CLND). Methods: Prospective multicenter study of the Departments of Dermatology of the Universities of Homburg/Saar, Tubingen and Munich (Germany) in which the distribution of lymph node and subcutaneous metastases were mapped from the scar of primary to the lymphatic drainage region in 53 melanoma patients ( 23 women, 30 men; median age: 64 years; median tumor thickness: 1.99 mm) with known primary, visible lymph nodes or subcutaneous metastases proven by ultrasound and histopathology during the follow-up. Results: Especially in the axilla, infraclavicular region and groin the metastases were not limited to the anatomic lymph node regions. In 5 patients (9.4%) ( 4 of them were in stage IV) lymph node metastases were not located in the corresponding lymph node area. 32 patients without former SLNB had a time range between melanoma excision and lymph node metastases of 31 months ( median), 21 patients with SLNB had 18 months ( p < 0.005). In 11 patients with positive SLNB the time range was 17 months, in 10 patients with negative SLNB 21 months ( p < 0.005); in 32 patients with CLND the time range was 31 m< 0.005). In thinner melanomas lymph node metastases occurred later ( p < 0.05). Conclusions: After surgery of cutaneous melanoma, SLNB and CLND the lymphatic drainage can show significant changes which should be considered in clinical and ultrasound follow-up examinations. Especially for high-risk melanoma patients follow-up examinations should be performed at intervals of 3 months in the first years. Patients at stage IV should be examined in all regional lymph node areas clinically and by ultrasound. Copyright (c) 2006 S. Karger AG, Basel

Complete mesocolic excision does not increase short-term complications in laparoscopic left-sided colectomies : a comparative retrospective single-center study

Background: Since the implementation of total mesorectal excision (TME) in rectal cancer surgery, oncological outcomes improved dramatically. With the technique of complete mesocolic excision (CME) with central vascular ligation (CVL), the same surgical principles were introduced to the field of colon cancer surgery. Until now, current literature fails to invariably demonstrate its oncological superiority when compared to conventional surgery, and there are some concerns on increased morbidity. The aim of this study is to compare short-term outcomes after left-sided laparoscopic CME versus conventional surgery. Methods: In this retrospective analysis, data on all laparoscopic sigmoidal resections performed during a 3-year period (October 2015 to October 2018) at our institution were collected. A comparative analysis between the CME group-for sigmoid colon cancer-and the non-CME group-for benign disease-was performed. Results: One hundred sixty-three patients met the inclusion criteria and were included for analysis. Data on 66 CME resections were compared with 97 controls. Median age and operative risk were higher in the CME group. One leak was observed in the CME group (1/66) and 3 in the non-CME group (3/97), representing no significant difference. Regarding hospital stay, postoperative complications, surgical site infections, and intra-abdominal collections, no differences were observed. There was a slightly lower reoperation (1.5% versus 6.2%, p = 0.243) and readmission rate (4.5% versus 6.2%, p = 0.740) in the CME group during the first 30 postoperative days. Operation times were significantly longer in the CME group (210 versus 184 min, p < 0.001), and a trend towards longer pathological specimens in the CME group was noted (21 vs 19 cm, p = 0.059). Conclusions: CME does not increase short-term complications in laparoscopic left-sided colectomies. Significantly longer operation times were observed in the CME group

Success rates of re-excision after positive margins for invasive lobular carcinoma of the breast.

Rates of positive margins after surgical resection of invasive lobular carcinoma (ILC) are high (ranging from 18 to 60%), yet the efficacy of re-excision lumpReceptor subtypeectomy for clearing positive margins is unknown. Concerns about the diffuse nature of ILC may drive increased rates of completion mastectomy to treat positive margins, thus lowering breast conservation rates. We therefore determined the success rate of re-excision lumpectomy in women with ILC and positive margins after surgical resection. We identified 314 cases of stage I-III ILC treated with breast conserving surgery (BCS) at the University of California, San Francisco. Surgical procedures, pathology reports, and outcomes were analyzed using univariate and multivariate statistics and Cox-proportional hazards models. We evaluated outcomes before and after the year 2014, when new margin management consensus guidelines were published. Positive initial margins occurred in 118 (37.6%) cases. Of these, 62 (52.5%) underwent re-excision lumpectomy, which cleared the margin in 74.2%. On multivariate analysis, node negativity was significantly associated with successful re-excision (odds ratio [OR] 3.99, 95% CI 1.15-13.81, p = 0.029). After 2014, we saw fewer initial positive margins (42.7% versus 25.5%, p = 0.009), second surgeries (54.6% versus 20.2%, p &lt; 0.001), and completion mastectomies (27.7% versus 4.5%, p &lt; 0.001). In this large cohort of women with ILC, re-excision lumpectomy was highly successful at clearing positive margins. Additionally, positive margins and completion mastectomy rates significantly decreased over time. These findings highlight improvements in management of ILC, and suggest that completion mastectomy may not be required for those with positive margins after initial BCS

Eccrine porocarcinoma of the head: An important differential diagnosis in the elderly patient

Background: Eccrine porocarcinoma is a rare malignant tumor of the sweat gland, characterized by a broad spectrum of clinicopathologic presentations. Surprisingly, unlike its benign counterpart eccrine poroma, eccrine porocarcinoma is seldom found in areas with a high density of eccrine sweat glands, like the palms or soles. Instead, eccrine porocarcinoma frequently occurs on the lower extremities, trunk and abdomen, but also on the head, resembling various other skin tumors, as illustrated in the patients described herein. Observations: We report 5 cases of eccrine porocarcinoma of the head. All patients were initially diagnosed as having epidermal or melanocytic skin tumors. Only after histopathologic examination were they classified as eccrine porocarcinoma, showing features of epithelial tumors with abortive ductal differentiation. Characteristic clinical, histopathologic and immunohistochemical findings of eccrine porocarcinomas are illustrated. Conclusion: Eccrine porocarcinomas are potentially fatal adnexal malignancies, in which extensive metastatic dissemination may occur. Porocarcinomas are commonly overlooked, or misinterpreted as squamous or basal cell carcinomas as well as other common malignant and even benign skin tumors. Knowledge of the clinical pattern and histologic findings, therefore, is crucial for an early therapeutic intervention, which can reduce the risk of tumor recurrence and serious complications. Copyright (c) 2008 S. Karger AG, Basel

Changes in and predictors of length of stay in hospital after surgery for breast cancer between 1997/98 and 2004/05 in two regions of England: a population-based

BACKGROUND Decreases in length of stay (LOS) in hospital after breast cancer surgery can be partly attributed to the change to less radical surgery, but many other factors are operating at the patient, surgeon and hospital levels. This study aimed to describe the changes in and predictors of length of stay (LOS) in hospital after surgery for breast cancer between 1997/98 and 2004/05 in two regions of England. METHODS Cases of female invasive breast cancer diagnosed in two English cancer registry regions were linked to Hospital Episode Statistics data for the period 1st April 1997 to 31st March 2005. A subset of records where women underwent mastectomy or breast conserving surgery (BCS) was extracted (n = 44,877). Variations in LOS over the study period were investigated. A multilevel model with patients clustered within surgical teams and NHS Trusts was used to examine associations between LOS and a range of factors. RESULTS Over the study period the proportion of women having a mastectomy reduced from 58% to 52%. The proportion varied from 14% to 80% according to NHS Trust. LOS decreased by 21% from 1997/98 to 2004/05 (LOSratio = 0.79, 95%CI 0.77-0.80). BCS was associated with 33% shorter hospital stays compared to mastectomy (LOSratio = 0.67, 95%CI 0.66-0.68). Older age, advanced disease, presence of comorbidities, lymph node excision and reconstructive surgery were associated with increased LOS. Significant variation remained amongst Trusts and surgical teams. CONCLUSION The number of days spent in hospital after breast cancer surgery has continued to decline for several decades. The change from mastectomy to BCS accounts for only 9% of the overall decrease in LOS. Other explanations include the adoption of new techniques and practices, such as sentinel lymph node biopsy and early discharge. This study has identified wide variation in practice with substantial cost implications for the NHS. Further work is required to explain this variation