Background
The MF07-01 trial is a multicenter, phase III, randomized, controlled study comparing locoregional treatment (LRT) followed by systemic therapy (ST) with ST alone for treatment-naïve stage ...IV breast cancer (BC) patients.
Methods
At initial diagnosis, patients were randomized 1:1 to either the LRT or ST group. All the patients were given ST either immediately after randomization or after surgical resection of the intact primary tumor.
Results
The trial enrolled 274 patients: 138 in the LRT group and 136 in the ST group. Hazard of death was 34% lower in the LRT group than in the ST group (hazard ratio HR, 0.66; 95% confidence interval CI, 0.49–0.88;
p
= 0.005). Unplanned subgroup analyses showed that the risk of death was statistically lower in the LRT group than in the ST group with respect to estrogen receptor (ER)/progesterone receptor (PR)(+) (HR 0.64; 95% CI 0.46–0.91;
p
= 0.01), human epidermal growth factor 2 (HER2)/neu(–) (HR 0.64; 95% CI 0.45–0.91;
p
= 0.01), patients younger than 55 years (HR 0.57; 95% CI 0.38–0.86;
p
= 0.007), and patients with solitary bone-only metastases (HR 0.47; 95% CI 0.23–0.98;
p
= 0.04).
Conclusion
In the current trial, improvement in 36-month survival was not observed with upfront surgery for stage IV breast cancer patients. However, a longer follow-up study (median, 40 months) showed statistically significant improvement in median survival. When locoregional treatment in de novo stage IV BC is discussed with the patient as an option, practitioners must consider age, performance status, comorbidities, tumor type, and metastatic disease burden.
Purpose: Beside recurrent laryngeal nerve (RLN), protection of the external branch of the superior laryngeal nerve (EBSLN) is required for complication-free thyroid surgery. This study investigates ...the contribution of intraoperative neuromonitoring (IONM) to identification and motor integrity of the EBSLN. Methods: This prospective study was performed on 245 EBSLNs in 147 patients with thyroid surgery. The rate of visual identification, contribution of IONM to functional localization, the rate and levels of recordable waveform amplitude from vocal cord (VC) movement were determined during surgery. Results: 164 (66.9%) EBSLNs were visually identified and additional 74 branches were functionally identified by IONM. Additional identification rate of IONM was 30.2%. Seven (2.9%) EBSLNs could not be identified during surgery. Cricothyroid muscle (CTM) twitch established functional integrity in 97.1% of EBSLNs. Electrophysiological stimulation of 151 (63.4%) EBSLNs created waveform amplitude >100 µV that mean amplitude level was calculated as 186 µV, and an amplitude >300 µV was recorded in 19 of 151 (12.6%) EBSLNs. Conclusions: In addition to visual identification, surgeons can functionally localize the EBSLN with the assistance of IONM that CTM twitch is a reliable evience for functional integrity of the EBSLN. In the majority of patients, stimulation of the EBSLN creates recordable waveform amplitude thus the EBSLN appears to be a second source of motor innervations for intrinsic laryngeal muscles.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Thyroid reoperations are surgically challenging because of significant anatomical variance. Visual and functional identification of the external branch of the superior laryngeal nerve (EBSLN) were ...studied in 2 groups of patients who underwent primary and redo thyroid surgery.
This study was conducted on 200 patients: 100 patients with redo and 100 patients with primary thyroid surgery. In addition to visual identification, nerve branches were functionally identified by intraoperative nerve monitoring (IONM). Visual, functional, and total identification rates of the EBSLN in both primary and redo surgery were determined and compared between the 2 groups.
We attempted to identify 138 and 170 EBSLNs at risk in redo and primary surgery, respectively. Visual identification rates were 65.3% and 30.4% (P < 0.001) in primary and redo surgery groups, respectively. In total, 164 (96.5%) and 97 EBSLNs (70.3%) were identified in primary and redo surgery, respectively (P < 0.001), including the use of IONM. In primary surgery group, 53 nonvisualized EBSLNs of 164 identified nerves (32.3%) were determined by IONM alone. In redo surgery group, 55 of 97 identified nerves (56.7%) were determined by IONM alone (P < 0.001).
Both visual and total identification rates of the EBSLN are significantly decreased in reoperative thyroidectomy. IONM increases the total identification rate of the EBSLN in primary and redo thyroid surgery. Electrophysiological monitoring makes a substantial contribution to the identification of the EBSLN both in primary and especially in redo thyroid surgery.
Antecedentes. El uso de quimioterapia neoadyuvante (QTN) en cáncer de mama (CB) menos agresivo es controversial. Objetivo: Investigar el efecto de la quimioterapia neoadyuvante en el cáncer de mama ...HER2 negativo luminal B. Método. Se evaluaron retrospectivamente pacientes entre enero de 2016 y diciembre de 2021. Resultados. Se incluyeron 128 pacientes. Los valores de corte para ki67 basados en el estado de respuesta patológica completa y el estadio tumoral tras la quimioterapia neoadyuvante fueron ≤ 40% y ≤ 35%, respectivamente. Según los hallazgos de la resonancia magnética previa a la quimioterapia neoadyuvante, la mastectomía solo fue viable en 90 pacientes, pero después de la quimioterapia neoadyuvante la cirugía conservadora de la mama fue posible en 29 (32%). Además, el 68.5% se volvieron elegibles para biopsia del ganglio linfático centinela después de la quimioterapia neoadyuvante, y se evitó la disección de ganglios linfáticos axilares en 38 pacientes (31.4%). Conclusiones. En las pacientes con cáncer de mama HER2 negativo luminal B, una tasa baja de respuesta patológica completa no debe desalentar el uso de quimioterapia neoadyuvante. En especial en pacientes jóvenes con niveles altos de ki67, la quimioterapia neoadyuvante aumenta la posibilidad de una cirugía conservadora de la mama y puede evitar que las pacientes sufran disección de ganglios linfáticos axilares.
Accurate restaging of the axilla after neoadjuvant chemotherapy (NAC) is an important issue to ensure deescalating axillary surgery in patients with initial metastatic nodes. We aimed to present our ...results of targeted axillary biopsy (TAB) combined with sentinel lymph node biopsy (SLNB) for axillary restaging after NAC.
In 64 breast cancer patients who underwent NAC, biopsy-proven positive nodes were marked with clips before NAC, and ultrasound-guided wire localization of clip-marked nodes was performed after NAC. Patients underwent TAB and SLNB for post-NAC axilla restaging.
Identification rates of post-NAC TAB and SLNB were 98.4% and 87.5%, respectively (P = 0.033). Histopathology revealed a nodal pathologic complete response (pCR) rate of 47% in which axillary lymph node dissection (ALND) was avoided. TAB alone and SLNB alone detected residual disease in 29 (85.3%) and 20 (58.8%) patients (P = 0.029), respectively. Whereas rates of up to 97% had been achieved with a combination of TAB and SLNB. The pCR rates after NAC were 64.3% for human epidermal growth factor receptor 2 positive and triple-negative tumors and 13.6% in luminal tumors (P = 0.0002).
Pathologic analysis following TAB combined with SLNB revealed the pCR rates to NAC in a considerable number of patients that provided de-escalation of axillary surgery. A combination of SLNB and TAB was found to be an accurate procedure in establishing residual nodal disease. This combined procedure in patients with initially positive nodes was a reliable method for post-NAC axillary restaging.
Idiopathic granulomatous lobular mastitis (IGLM) is a rare chronic inflammatory disease of the breast with obscure etiology that mimics invasive carcinoma both clinically and radiologically. The ...treatment of IGLM remains controversial. The aim of proper management is to use a combination of medical and surgical treatment of this benign condition to achieve a good cosmetic result and low recurrence rate.
A retrospective analysis of 19 patients with IGLM is performed based on the findings of clinical, radiological, and pathological examinations. The results of two treatments are presented: medical treatment with oral corticosteroids, and consecutive surgical excision after a follow-up period of 20 months (range, 6-75 months).
The majority of patients treated in this paper were young (mean, 34 years) parous women with a history of hormonal medication use. The main clinical finding is large, irregular, and painful mass. Hypoechoic lobulated, irregular tubular or oval shaped masses had been imaged by ultrasound. Mammographic findings were an ill-defined mass, enlarged axillary lymph nodes, asymmetric density, and architectural distortion. Diagnoses of IGLM had been established by cytological or histological examination. Symptoms subside and inflammatory changes regressed with medical treatment. The remaining lesions were excised by consecutive breast conserving surgery. The disease recurred in one patient during the follow-up period.
IGLM is an inflammatory breast disease found in young women who present with a large painful irregular mass, which mimics carcinoma, as a physical change. Breast imaging modalities are not helpful to differentiate IGLM from invasive cancer. The correct diagnosis is established by cytological or histological examination. Medical treatment with corticosteroids provides significant regression of the inflammatory disease, allowing more conservative surgery. Consecutive surgical excision of the remaining lesions with good cosmetic results provides definitive treatment and reduces the risk of recurrence.
PurposeCases of adhesive small bowel obstruction are a nuisance to surgeons. There have been years of ongoing discussions, and various guidelines have been published for the management of this ...disease. Both surgical and conservative approaches can have their own complications. It is often difficult to decide which treatment to apply to which patient. We aimed to create a multiparametric scoring system for the optimal management of adhesive small bowel obstruction patients. MethodsThe retrospective laboratory, clinical and radiological records of 100 patients who were hospitalized and followed-up/treated for adhesive small bowel obstruction secondary to surgery in the General Surgery Clinic of Haydarpaşa Numune Education and Research Hospital (Istanbul) between 2011 and 2021 were reviewed and statistically analyzed. ResultsAdmittance CRP and the largest diameter of the small intestine in the horizontal section of the admittance CT scans were significantly higher (P = 0.006 and P = 0.007), and the admittance albumin and sodium values were significantly lower (P < 0.001 and P = 0.031) in patients operated on for adhesive small bowel obstruction than in patients not operated on. Free intraperitoneal fluid in CT scans was detected at a higher rate in the operated group. An adhesive small bowel obstruction surgery score above 3.5 points out of 7 was found to be significant (P < 0.001). ConclusionWith this easy and applicable scoring system, complications of existing disease may be avoided by considering earlier surgical intervention in patients with a score of 4 and above.
Complication-free thyroid surgery is mainly based on the motor integrity of the recurrent laryngeal nerve (RLN). The nonrecurrent laryngeal nerve (non-RLN) is a rare anatomical variation that may ...increase the risk of vocal cord palsy. Early identification and exposure of the non-RLN may minimize injury risk. This case report presents functional detection of the non-RLN by intraoperative neuromonitoring (IONM). Total thyroidectomy was performed under the guidance of IONM on a patient with bulky multinodular goiter. The first step of IONM is pre-dissection stimulation (V1) of the right vagus nerve (VN). V1 at a standard distal point was negative as indicated by the absence of both a sound signal and wave amplitude. The right VN was then followed proximally and dissected under the guidance of IONM. This dissection established a proximal point creating a positive signal that led us to determine the separation point of the non-RLN. The right non-RLN arising from the proximal VN was identified and fully exposed until laryngeal entry. Its motor integrity was confirmed with post-dissection signals. The left RLN was identified at the usual anatomical position that was fully exposed and preserved during thyroid surgery. Total thyroidectomy was then accomplished without complication. The postoperative period was uneventful. Postoperative laryngoscopy confirmed normal vocal cord function. The non-RLN is accurately identified by IONM during the early part of the thyroid surgery. The absence of a distal VN signal is predictive of the non-RLN. IONM-guided proximal dissection of the right VN leads to the identification of the non-RLN. The prediction of the non-RLN by the absence of a VN signal during an early stage of surgery may prevent or minimize the risk of nerve injury.
Safe thyroid surgery depends on a deep knowledge of human neck anatomy, including the recurrent laryngeal nerve (RLN). Anatomic variations such as extra-laryngeal terminal branching (ETB) are common.
...We studied the ETB pattern of 1001 RLNs at risk in 596 patients. We identified and exposed the location of division points on the cervical part of bifid RLN. The function of nerve branches was assessed through intraoperative nerve monitoring (IONM).
Bifid RLNs was identified in 39.6% of patients. The nerve-based prevalence of ETB was 28.5%. The prevalence of ETB for the right and left RLN was 21.8% and 35.5%, respectively (p < 0.001). The location of the division point was found in the middle, distal, and proximal segments in 48.8%, 33.3%, and 18% of bifid RLNs, respectively. Electrophysiological monitoring revealed motor functions in all anterior and in 7% of posterior branches. The rate of injury was 0.4%, and 1.1% in single trunk and bifid nerves, respectively (p = 0.360), and 3.9% in nerves with proximal branching (p = 0.084).
The ETB prevalence is high and showing division points in different cervical segments of the RLN. All anterior branches and some posterior branches contain motor fibers. Knowledge and awareness of these anatomic and functional variations are mandatory for every thyroid surgeon to avoid misidentification and misinterpretation of human RLN anatomy.
Thyroid hemiagenesis (TH), very rare congenital anomaly, is generally asymptomatic. We report two cases of TH with hyperthyroidism. Case One. The patient presented with signs and symptoms of ...thyrotoxicosis. Physical examination revealed asymmetric nodular goitre at right lobe. Biochemical analysis revealed the diagnosis of hyperthyroidism. Ultrasound showed multinodular hypertrophy in the right lobe and absence of the left lobe. Nuclear scan, confirming absence of the left lobe, showed hot nodules in the right one. The diagnosis was toxic multinodular goitre. Case Two. The thyroid was not palpable in this patient presented with signs and symptoms of thyrotoxicosis. Biochemical analysis revealed the diagnosis of autoimmune thyrotoxicosis. Ultrasound showed mild diffuse hyperplasia of the right lobe and agenesis of the left lobe. Nuclear scan, confirming absence of the left lobe, showed increasing diffuse uptake of radiotracer in the right one. The diagnosis was Graves’ disease in this patient. After antithyroid medication, the patients were surgically treated with total excision of the thyroid tissue. TH is sometimes associated with disorders of the thyroid. Hyperthyroidism makes TH cases symptomatic. During evaluation of patients, ultrasound and nuclear scan usually report agenesis of one lobe and establish the diagnosis of TH. The surgical treatment is total removal of hyperactive tissue and total excision of the remaining lobe.
PDF
