Aggressive Surgery Research Articles

Influence of germline test results on surgical decision making in women with invasive breast cancer

BackgroundWhile therapeutic mastectomy with contralateral prophylactic mastectomy (TM+CPM) and/or bilateral salpingo-oophorectomy (BSO) are recommended for women with pathogenic variants (PV) in some cancer predisposition genes, evidence for the utility of these surgeries for women with PV in other genes currently is insufficient. In conjunction, current guidelines recommend that clinical management should not be influenced by a return of a variant of uncertain significance (VUS). Return of germline test results may, however, influence surgical decision making regardless of current guidelines. We thus evaluated surgical choices amongst a cohort of women with invasive breast cancer who underwent clinical genetic testing. MethodsGermline test results and all surgical procedures were extracted for women who had unilateral invasive breast cancer and had clinical testing before definitive surgery (n = 591). Results were classified as pathogenic/likely pathogenic (PV, 17.1%), VUS (19.5%) or benign/likely benign (63.4%). Data were analyzed using chi-square tests with p<0.05 defining significance. ResultsRates of TM+CPM and BSO were not significantly different for women with VUS compared to those with benign findings. Rates of TM+CPM were significantly higher for women with PV in BRCA1 and BRCA2, PALB2, PTEN and TP53, as well in genes with insufficient data to recommend risk-reducing mastectomy. Rates of BSO were significantly higher in women with PV in BRCA1 and BRCA2, PALB2, PTEN and TP53 and BRIP1, RAD51C and RAD51D compared to those with benign findings. ConclusionOverall, surgical choices for women with a VUS were more similar to those from women with benign variants than to those with PV, however, in the group with PV in genes for which insufficient evidence exists for the benefit of risk-reducing mastectomy, rates of TM+CPM were high. Thus, while the management of women with VUS is in agreement with ACMG guidelines, patients with mutations in other cancer genes demonstrate a preference for more aggressive breast surgeries.

Surgical outcomes and prognostic factors of distal common bile duct adenocarcinoma: chronological analysis in a single high-volume institutional experience

BackgroundDistal common bile duct (dCBD) cancer is typical indication for pancreaticoduodenectomy (PD). We aimed to retrospectively evaluate surgical outcomes and investigate prognostic factors of dCBD adenocarcinoma for which PD was performed at a single institution.MethodsWe searched consecutive cases of dCBD adenocarcinoma undergone PD at Samsung Medical Center from 1995 to 2018. Cases with distant metastasis or palliative intent were excluded. The year in which the survival rate was dramatically improved was identified and entire years were divided into two periods for comparison. To balance between the two periods, we conducted propensity score matching (PSM) analysis using age, sex, body mass index (BMI), and American Society of Anesthesiologist score.ResultsTotal of 804 cases were enrolled in this study. The entire period was divided into early period of 18 years and recent period of 6 years. The early and late period included 466 and 338 patients, respectively. As a result of PSM, balanced 316 patients were selected from each of the two periods. Significant improvements in surgical outcomes were identified, including shorter operation time, fewer blood loss, shorter hospitalization, and favorable overall survival. As results of multivariable analysis of independent risk factors for overall survival, older age and advanced N stage were identified, as expected. It was distinct that aggressive surgery and advanced tumor state in the early period and a lower BMI in the late period negatively affected the survival, respectively.ConclusionsSurgical outcomes of dCBD cancer underwent PD was improved. There were few modifiable factors to improve survival and continuous further study is needed to detect dCBD cancer in the early stages.

Highly Aggressive Surgery Benefits in Patients With Advanced Ovarian Cancer.

We investigated whether highly aggressive surgery has survival and perioperative complication benefit in patients with advanced ovarian cancer. This retrospective study included 209 patients with stage III/IV ovarian cancer who underwent aggressive surgery [surgical complexity score (SCS) ≥8] between January 2008 and December 2018. Patients were categorized into the SCS 8-12 (less aggressive surgery, 83 patients) and SCS ≥13 (highly aggressive surgery, 126 patients) groups. Survival outcomes and perioperative complications between the groups were compared. Patient suitability for primary debulking surgery or neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) was based on the evaluation of performance status, tumor load, and ascites. If patients were suitable for NACT/IDS, the residual tumor margins were marked at the initial laparotomy. The previously marked lesions were removed during IDS, even in patients with macroscopic tumor resolution. Prevalence rates of stage IV disease, poor performance status, presence of omental cake, peritoneal cancer index ≥15, and IDS performed were significantly higher in the highly aggressive surgery group than in the less aggressive surgery group. The median progression-free survival (PFS) and overall survival (OS) were not significantly different between the groups (PFS, 32 and 31 months, respectively; p=0.622; OS, 99 and 75 months, respectively; p=0.390). The incidence of severe perioperative complications was not significantly different between the less aggressive group (4.8%) and the highly aggressive surgery group (6.4%) (p=0.767). Highly aggressive surgery with appropriate selection regardless of the timing of cytoreduction benefits patients with advanced ovarian cancer.

COMPARISON OF OUTCOMES OF ILEOSTOMY,PRIMARY REPAIR AND RESECTION ANASTOMOSIS FOR ILEAL PERFORATION IN TERTIARY CARE HOSPITAL

ntroduction: Ileal perforation peritonitis is a commonly encountered surgical emergency in the Indian subcontinent and in tropical countries. Despite the availability of modern diagnostic facilities and advances in treatment regimes, this disease has an abrupt onset and a rapid downhill course with a high mortality if not treated [1,2]. Better antibiotics, aggressive surgery and the elimination of conservative treatment, better preoperative and postoperative management have all signicantly contributed to the improvement in patient outcome. The present studyMethods: includes 50 patients of ileal perforation with emphasis on typhoid, nonspecic and traumatic perforations, their preoperative and postoperative management and the factors inuencing outcome. This was an observational study of patients presented with ileal perforation managed with operative management like primary closure , resection- anastomosis and ileostomy Fever and abdominal pain were the most common. Result: clinical presentations. Ileostomy was performed in the majority of the cases after proper preoperative resuscitation , general condition of patient and intra-operative ndings. Nonspecic was the leading cause followed by typhoid. Abdominal pain, fever and vomiting were theDiscussion: most common symptoms of peritonitis. Most of the patients with ileal perforation have single perforation of size ranging 0.5-1 cm. Ileostomy as a treatment modality performed in 28 patients out of 50 Ileostomy may be given priority over other surgical options especially in those. Conclusion: moribund patients who present late in the course of their illness, have more than one perforation with massive fecal contamination of the abdominal cavity. Primary closure of perforation is a preferred technique in clinically stable patients with a single perforation with minimal soiling of the abdominal cavity. After adequate preoperative resuscitation , loop ileostomy holds the best result in terms of complications like postoperative leak, intra abdominal abscess, fecal stula, peritonitis, septicemia, paralytic ileus.

Alternating pattern of rhino-orbital-cerebral mucormycosis with COVID-19 in diabetic patients.

PurposeOur aim was to analyze the patients with diabetic rhino-orbital–cerebral mucormycosis that we have treated in our clinic in the last 5 years, and to reveal the altering conditions with COVID-19.Materials and methodsA retrospective study was conducted on 39 rhino-orbital–cerebral mucormycosis (ROCM) patients with diabetes mellitus between 2017 and 2022. The patients were divided into two groups as those associated with and not associated with COVID-19 and compared.ResultsThirty-nine diabetic patients were included in the study, with 15 (38.5%) of them being COVID-19 associated mucormycosis (CAM) group. CAM patients showed higher orbital involvement and cavernous sinus involvement (p = 0.002 and p = 0.013, respectively). The mortality rate in the non-COVID-19 associated mucormycosis (non-CAM) group was statistically higher in patients with intracranial and cavernous sinus involvement (p = 0.015 and p = 0.033, respectively). The difference between the overall survival of the CAM patients and non-CAM patients was not statistically significant (p = 0.741).ConclusionsWith COVID-19, progressive mucormycosis accompanied by orbital and intracranial involvement is observed more frequently. However, on the contrary, the mortality rate in COVID-19-associated mucormycosis is considerably lower than expected. The fact that temporary immune suppression can be ameliorated with adequate supportive treatment and liposomal amphotericin-B which can be given to patients in high doses may explain this situation. It has been attained hints that the essential factor in the treatment of COVID-19-associated ROCM is the control of the underlying disease and to be cautious in the decision of early aggressive surgery.

Potential role of hybrid positron emission tomography in pre-operative assessment of primary salivary gland carcinomas.

The added value of hybrid positron emission tomography is increasingly recognised in head and neck cancer. However, its potential role in salivary gland carcinomas has been scarcely investigated. A consecutive cohort of 45 salivary gland carcinoma patients who underwent pre-therapeutic hybrid positron emission tomography and surgical resection was reviewed. This study investigated whether maximum standardised uptake value correlated with tumour phenotype. Tumours of high-grade disease on histology (salivary duct carcinoma, carcinoma ex pleomorphic adenoma) had higher maximum standardised uptake value (Kruskal-Wallis test, p = 0.011) than low-grade tumours (adenoid cystic carcinoma and acinic cell carcinoma). Patients with pathologically confirmed node-positive disease had significantly higher maximum standardised uptake value of the primary tumour than patients with pathologically confirmed node-negative disease (Kruskal-Wallis test, p = 0.012). Maximum standardised uptake value of the primary tumour may guide clinical decision-making in patients with salivary gland carcinomas, as a high maximum standardised uptake value is associated with high-grade tumour histology and the presence of lymph node metastases. Clinicians may consider more aggressive surgery for these patients.

Abstract 6092: The dual roles of C-X-C MOTIF chemokine LIGAND 10 in pediatric osteosarcoma

Abstract Osteosarcoma is the most common malignant bone tumor in children and young adults. Despite the use of multi-agents chemotherapy and aggressive surgery, the survival of patients with osteosarcoma remains at 60% over the past three decades. In addition, the survival of patients who develop metastasis is dismal and often less than 25%. We have previously reported that serum C-X-C motif chemokine ligand 10 (CXCL10) is associated with survival in a large cohort of osteosarcoma patients. CXCL10 is an interferon-induced chemokine that binds to its cognate receptor CXCR3 to elicit its cellular effects via both autocrine and paracrine signaling. CXCL10 can promote tumor cell migration and metastasis via autocrine signaling, while it recruits CXCR3+ immune cells to exert a tumoricidal effect via paracrine signaling. However, little is known about the effect of circulating CXCL10 in cancer. To understand the role of CXCL10 in the pediatric bone tumor, we showed that a number of osteosarcoma cell lines expressed the CXCR3 protein. The addition of exogenous CXCL10 promoted tumor cell migration of three osteosarcoma cell lines but did not affect cell proliferation. However, the migratory effect of osteosarcoma cells is not specific to CXCL10, as other CXCR3-associated chemokines (CXCL4, CXCL9, and CXCL10) exerted similar effects. Using an orthotopic xenograft mouse model, we demonstrated intravenous injection of CXCL10 increased the development of pulmonary metastases of osteosarcoma. In contrast, expression profiling of osteosarcoma primary tumors showed that elevated expression of CXCL10 and CXCR3 was associated with a better prognosis, suggesting that a paracrine effect of CXCL10 by recruiting CXCR3+ immune cells to the tumor site. This notion is supported by our immune cell population deconvolution results, indicating that the predominant infiltrating immune cell types are macrophages and CD8+ T cells. Taken together, our results suggest a model in which CXCL10 may play both pro-tumor and anti-tumor roles in osteosarcoma. While a high level of exogenous or circulating CXCL10 may promote tumor cell migration and metastasis, the chemokine can also recruit CXCR3+ immune cells to exert a favorable prognostic effect. Further characterization of the sources of CXCL10 in the tumor site and circulation may lead to the development of a therapeutic approach that promotes CXCL10’s anti-tumor effects and minimizes its pro-tumor effects to improve the survival of osteosarcoma patients. Citation Format: Xiang Chen, Margaret Clement, John Hicks, Tsz Kwong Man. The dual roles of C-X-C MOTIF chemokine LIGAND 10 in pediatric osteosarcoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6092.

Diabetes mellitus postoperatif hipoparatiroidizm için bir risk faktörü olabilir mi?

Aim: Postoperative hypoparathyroidism (postop hypoPT) is usually seen after aggressive neck surgery, and can be fatal if left untreated. To the best our knowledge there is no study in literature that directly investigates the association between diabetes mellitus (DM) and postop hypoPT. In this study, we aimed to determine whether DM increases the risk of permanent postop hypoPT. Materials and Methods: Patients presenting to endocrinology outpatient clinic with a diagnosis of permanent postoperative hypoparathyroidism, were studied retrospectively. Patients older than 18 years of age were included in the study if one year had passed after the neck operation. Results: The average age of 131 patients who met the inclusion criteria was 49 ± 12. 93.9% of the patients were women and the patients were generally obese or overweight (mean body mass index= 30±5.29 kg/m2). While 14.5% of the patients were diabetic and 32.8% prediabetic (47.3% had impaired carbohydrate tolerance), 52.7% had normal glucose metabolism. Conclusion: The rate of DM / prediabetes (preDM) in patients diagnosed with postop hypoPT and the prevalence of DM / preDM in Turkish population were similar. Even though DM is associated with endothelial dysfunction, our findings suggest that DM is not a risk factor for postop hypoPT.

Clinical characteristics and prognostic analyses of cervical neuroblastoma

Objective: To determine the characteristics of cervical neuroblastoma and the effect of resection extent on survival and outcomes. Methods: We performed a retrospective review of 32 children with cervical neuroblastoma treated at Beijing Children's Hospital between April 2013 and August 2020. Data were collected from the medical record. The individualized therapy was designed based on staging and risk group. Based on the extent of resection, patients were divided into incomplete and complete resection groups. Event free and overall survival rates were compared between two groups using the Kaplan-Meier method. Results: The ages of patients ranged from 1 month to 81 months, with a median age of 11 months, including 7 males and 15 females. Twenty-nine patients (90.6%) presented with cervical painless mass. The average diameter of the primary tumors was (5.12±1.43) cm. Tumors were located in the parapharyngeal space in 25 cases (78.1%) and in the root of the neck in 7 cases (21.9%). None had MYCN amplification. According to International Neuroblastoma Staging System (INSS), 15 patients (46.9%) were identified as stage 1, 11 patients (34.3%) as stage 2B, 3 patients (9.4%) as stage 3 and 3 patients (9.4%) as stage 4. There were 12 patients (37.5%) at low risk, 17 patients (53.1%) at intermediate risk and 3 patients at high risk according to Children's Oncology Group (COG) risk classification system. All patients underwent tumor resection. Postoperatively Horner's syndrome occurred in 13 patients (40.6%), pneumonia in 9 patients (28.1%), pharyngeal dysfunction in 8 patients (25.0%) and transient hoarseness in 4 patients (12.5%). At a median follow-up of 36.5 months, the overall survival rate was 96.4%, with no significant difference between incomplete and complete resection groups (100.0% vs. 96.3%, χ2=0.19, P=0.667); the event free survival rate was 78.1%, with a significant difference between the two groups (40.0% vs. 85.2%, χ²=6.71, P=0.010). Conclusions: Primary cervical neuroblastoma has a young onset age, mostly in low and medium risk groups, and represents favorable lesions with good outcomes after multidisciplinary therapy. Less aggressive surgery with preservation of important structures is recommended. Complete resection should not be attempted if it would compromise vital structures.

Patient-centered Outcomes in Breast Cancer: Description of EQ-5D-5L and EORTC-QLQ-BR23 Measurements in Real-world Data and Their Association With Survival

AimsIn recent years, major improvements in breast cancer treatments have led to a significant increase in survival. Despite that, this population's quality of life (QoL) information is lacking, especially real-world data. Materials and methodsThis was a prospective, multicentre, observational study of female breast cancer patients, without prior systemic treatment, treated between 2012 and 2019 in private health care in Brazil. QoL was assessed by two questionnaires, the EQ-5D-5L and the EORTC-QLQ-BR23. Additional data were retrospectively collected. ResultsThe study comprised 1372 patients, most with early-stage disease (80.2% stages 0–II). At a median follow-up of 25.6 months, the estimated 3-year overall survival was 93.6%. Patients with locally advanced and metastatic breast cancer had the lowest visual analogue scale scores and the highest symptom burden in all dimensions of EQ-5D-5L, but with the most significant improvement after treatment. With the EORTC-QLQ-BR23 questionnaire, patients undergoing lumpectomy had a better perception of body image. Axillary dissection led to greater arm symptoms after 12 months, radiotherapy enhanced breast symptoms and patients treated with chemotherapy had significant worsening in the effects of systemic therapy compared with endocrine or HER2 therapy. Staging and immunohistochemical subtype correlated with survival and with several QoL parameters, but overall survival was not independently affected by patient-reported outcomes in this cohort. ConclusionOur results show that early diagnosis and access to treatments with fewer side-effects, such as endocrine or targeted therapy, and less aggressive surgeries are the best strategies to achieve a better QoL for breast cancer patients.

Axillary dissection 10 years after Z0011.

e12582 Background: Axillary involvement is one of the strongest prognostic factors in breast cancer. Axillary lymphadenectomy (AL) has been considered one of the milestones to reduce relapse risk of local breast carcinoma. Z0011 trial, demonstrated that axillary dissection was not necessary in cases with one or two nodes involved. The authors proposed 3 sentinel nodes to decide if AL should be done. Since in the trials that explored the omission of lymphadenectomy obtained between one and six nodes, there is no consensus about how many lymph nodes should be obtained in the axillary sampling. The objective of this study is to obtain real data about axillary staging in real practice after Z0011 trial. Methods: 197 patients were selected from clinical records of Hospital Universitario de Torrejon. All patients were diagnosed with localized infiltrating breast carcinoma between 2016 and 2021. All were candidates for sentinel node biopsy (SNB) analyzed by OSNA or histopathology analysis. Patients with in situ tumors, those who underwent neoadjuvant chemotherapy We retrospectively reviewed the number of axillary nodes obtained in SNB and if axillary dissection was performed or not. Results: From 197 patients, 150 were included in the study (47 were excluded because were diagnosed with in situ carcinoma, received neoadjuvant chemotherapy or followup was lost). All 150 women were patients with infiltrating breast cancer who underwent conservative surgery or mastectomy and SNB. After surgical treatment, all patients received subsequent therapies indicated in each case (chemotherapy, radiotherapy or hormone therapy). Medium age at diagnosis was 57 years (range 30-87). Median number of sentinel nodes obtained in SNB was 2 (range 1 to 5). 40 patients had tumor infiltration in SNB, but only 15 underwent axillary dissection,10 of them had one node involved, 4 had 2 nodes involved and one had 3 nodes involved, from up to four extracted. 5 patients had more node involved than those found on the sentinel node biopsy, and all had macrometastasis. Capsular rupture was identified in 7 cases. None of the patients had relapse until the time of follow up was closed. Conclusions: Rate of axillary dissection after Z0011 has decreased without increasing risk of loco-regional or distant relapse. During the time of surgery, not always is possible to obtain 3 sentinel nodes, which could involve more aggressive surgery and comorbidities. Techniques of sentinel node identification are needed and further investigation to resolve in which cases axillary dissection is unavoidable.

Abstract IA013: Genetic heterogeneity and tumor microenvironment in glioblastoma

Abstract Glioblastoma (GBM), the most aggressive brain tumor, remains an unmet medical need. Despite aggressive chemotherapy, radiation and surgery, only 5.6% of patients survive beyond 5 years post-diagnosis. Targeted approaches have not been successful in this tumor type due to the extreme heterogeneity of GBM. Mosaic amplification of oncogenes suggests that multiple genetically distinct clones are present in each tumor. However, little is known about how different subpopulations of GBM cells interact with each other or with the surrounding tumor microenvironment (TME). To address this, we employed spatial protein profiling coupled with single-cell spatial maps of fluorescence in situ hybridization (FISH) for key oncogenes frequently amplified in GBM. Our analysis spanned 3-4 areas from 17 formalin-fixed paraffin-embedded (FFPE) GBM cases, 96 sub-regions of interest and total of 35,843 single nuclei. Digital spatial profiling for 79 protein markers associated with GBM biology, TME and neurobiology revealed high intra-tumor variability of vasculature, between distinct regions of the same tumor biopsy. The single-cell FISH signal quantification allowed us to classify tumors based on the relative frequency of cells harboring co-occurring of EGFR and CDK4 amplifications. Tumors with low odds ratio for EGFR and CDK4 co-amplification in a cell had a significantly higher EGFR copy number in cells harboring this amplification. Cell-to-cell variation in EGFR copy number was also much higher in these tumors, suggesting a possibility for extrachromosomal origin of this amplification. Interestingly, the tumors with high frequency of cells harboring co-amplification of EGFR and CDK4 exhibit higher infiltration by CD163+ immunosuppressive macrophages. Our results suggest that high throughput assessment of genomic alterations at the single cell level could provide a measure for predicting the immune state of GBM. Citation Format: Kacper A. Walentynowicz, Dalit Engelhardt, Shreya Yadav, Ugoma Onubogu, Roberto Salatino, Cristina Vincentelli, Thomas O. McDonald, Franziska Michor, Michalina Janiszewska. Genetic heterogeneity and tumor microenvironment in glioblastoma [abstract]. In: Proceedings of the AACR Special Conference on the Evolutionary Dynamics in Carcinogenesis and Response to Therapy; 2022 Mar 14-17. Philadelphia (PA): AACR; Cancer Res 2022;82(10 Suppl):Abstract nr IA013.

Real clinical practice of complicated Crohn’s disease treatment with ustekinumab: clinical case presentation

Crohn’s disease (CD) is a severe immune-mediated disease with segmental transmural inflammation and ulcers in gastrointestinal tract most often in terminal ileum and colon. The disease is often associated with severe complications such as fistulas and strictures that require aggressive treatment or surgery. CD treatment remains the unresolved and one of the most serious problems in gastroenterology. Glucocorticosteroids (GCS) are the essential treatment options for many years but unfortunately the frequency of steroid resistance and steroid dependence are constantly increasing. In the cases of steroid refractory CD treatment options include biologics of different classes: tumour necrosis factor alfa - inhibitors (iTNF-α), α4β7 integrin inhibitor (vedolizumab), IL-12/23 inhibitor (ustekinumab). Any of these drugs can be used in bio-naïve CD patients, however secondary loss of response was noted for all biologics over time.In the cases of the first line treatment failure the problem of correct choice of the second and subsequent lines of biologics appears, since some biologics may show lower efficacy in the second line of treatment. Real clinical practice will allow us to make a more correct choice of next biologic. Ustekinumab, a human interleukin -12/23 monoclonal antibody is one of biologics that is highly effective in the first-line CD therapy and remains effective in the subsequent lines of treatment. We present a clinical case of complicated CD in young female with negative disease prognosis and loss of response to three iTNF-α. In this case the high efficacy of ustekinumab after multiple iTNF-α failure was demonstrated.

Surgical Indications and Outcomes of Resection for Pancreatic Neuroendocrine Tumors with Vascular Involvement.

Simple SummaryPancreatic neuroendocrine tumors (pNETs) are a heterogenous group of rare epithelial neoplasms. For most patients, surgery remains the only treatment modality to cure pNETs, and is recommended for patients with surgically resectable disease. Many of these tumors are non-functional tumors and do not produce clinical symptoms, so patients may present with locally advanced tumors, which invade surrounding organs or neighboring blood vessels. The presence of vascular involvement had previously been considered a contraindication to surgery, but, in recent years, at centers with considerable experience, aggressive surgery to remove pNETs with vascular reconstruction has been performed safely and with good long-term survival. In this review, we will discuss the considerations for resectability, review novel surgical approaches, and present the available evidence on the immediate and long-term postoperative outcomes.Complete surgical resection of pancreatic neuroendocrine tumors (pNETs) has been suggested as the only potentially curative treatment. A proportion of these tumors will present late during disease progression, and invade or encase surrounding vasculature; therefore, surgical treatment of locally advanced disease remains controversial. The role of surgery with vascular reconstruction in pNETs is not well defined, and there is considerable variability in the use of aggressive surgery for these tumors. Accurate preoperative assessment is critical to evaluate individual considerations, such as anatomical variants, areas and lengths of vessel involvement, proximal and distal targets, and collateralization secondary to the degree of occlusion. Surgical approaches to address pNETs with venous involvement may include thrombectomy, traditional vein reconstruction, a reconstruction-first approach, or mesocaval shunting. Although the amount of literature on pNETs with vascular reconstruction is limited to case reports and small institutional series, the last two decades of studies have demonstrated that aggressive resection of these tumors can be performed safely and with acceptable long-term survival.

Localized gastric mesothelioma with nodal metastasis-an exceptionally rare entity.

Localized mesothelioma is a rare disease with very few reports of presentation in visceral organs. We report a case of localized gastric mesothelioma with lymph node metastasis in a 32-year-old man without asbestos exposure. A failed attempt at resection was made before presentation at another center. He was given perioperative chemotherapy that was followed by a D2 radical subtotal gastrectomy and hyperthermic intraperitoneal chemotherapy. Histopathology showed epithelioid mesothelioma with nodal metastasis but without visceral peritoneal involvement. Cytoreductive surgery and regional chemotherapy are standard in diffuse mesothelioma. Management of localized mesothelioma is anecdotal; however aggressive surgery plays a central role with selective use of perioperative chemotherapy.

Intraductal Delivery and X-ray Visualization of Ethanol-Based Ablative Solution for Prevention and Local Treatment of Breast Cancer in Mouse Models

Breast cancer is the most prevalent cancer and the second-leading cause of cancer-related death for women in the USA. For high-risk women, prophylactic mastectomy is the most effective primary prevention strategy. Prophylactic mastectomy is an aggressive surgical procedure that completely removes the mammary epithelial cells from which breast cancer arises along with the surrounding tissue. We seek to develop a minimally invasive intraductal procedure as an alternative to prophylactic mastectomy to locally ablate the mammary epithelial cells before they can become malignant. We and others have developed an intraductal delivery procedure to reach and treat these epithelial cells in rodent models of breast cancer. While the mouse mammary gland with a single non-anastomosed ductal tree opening at the nipple has a much less complex and tortuous architecture than the human breast, chemically induced and genetically engineered mouse models of breast cancer are valuable to produce proof-of-concept studies of new preventative strategies. Here, we describe a procedure for intraductal delivery of an ethanol-based ablative solution containing micro-CT/X-ray tantalum-based contrast agent within the mouse mammary ductal tree for the therapeutic purpose of primary prevention of breast cancer. Intraductal delivery of aqueous reagents (e.g., cytotoxic compounds, siRNAs, AdCre) has been previously described in mouse models. Thus, we focus our protocol description on methodological modifications and unique experimental considerations for optimizing delivery of ethanol, for minimizing local and systemic side effects of ethanol administration, and for in vivo visualization of ductal tree filling via micro-CT/fluoroscopy imaging. Visualization of the ductal tree immediately after injection of a contrast-containing solution allows for confirmation of complete filling or unsuccessful outcomes such as underfilling or overfilling. This procedure can be applied for delivery and imaging of other ablative compounds aimed at either preventing tumor formation or locally treating early-stage tumors accessible via the ductal tree.

Intraductal Delivery and X-ray Visualization of Ethanol-Based Ablative Solution for Prevention and Local Treatment of Breast Cancer in Mouse Models.

Breast cancer is the most prevalent cancer and the second-leading cause of cancer-related death for women in the USA. For high-risk women, prophylactic mastectomy is the most effective primary prevention strategy. Prophylactic mastectomy is an aggressive surgical procedure that completely removes the mammary epithelial cells from which breast cancer arises along with the surrounding tissue. We seek to develop a minimally invasive intraductal procedure as an alternative to prophylactic mastectomy to locally ablate the mammary epithelial cells before they can become malignant. We and others have developed an intraductal delivery procedure to reach and treat these epithelial cells in rodent models of breast cancer. While the mouse mammary gland with a single non-anastomosed ductal tree opening at the nipple has a much less complex and tortuous architecture than the human breast, chemically induced and genetically engineered mouse models of breast cancer are valuable to produce proof-of-concept studies of new preventative strategies. Here, we describe a procedure for intraductal delivery of an ethanol-based ablative solution containing micro-CT/X-ray tantalum-based contrast agent within the mouse mammary ductal tree for the therapeutic purpose of primary prevention of breast cancer. Intraductal delivery of aqueous reagents (e.g., cytotoxic compounds, siRNAs, AdCre) has been previously described in mouse models. Thus, we focus our protocol description on methodological modifications and unique experimental considerations for optimizing delivery of ethanol, for minimizing local and systemic side effects of ethanol administration, and for in vivo visualization of ductal tree filling via micro-CT/fluoroscopy imaging. Visualization of the ductal tree immediately after injection of a contrast-containing solution allows for confirmation of complete filling or unsuccessful outcomes such as underfilling or overfilling. This procedure can be applied for delivery and imaging of other ablative compounds aimed at either preventing tumor formation or locally treating early-stage tumors accessible via the ductal tree.

Fournier’s gangrene: the current state of the problem and our treatment experience

The OBJECTIVE of the study was to analyze the results of treatment of patients with lightning scrotal gangrene (Fournier’s gangrene).METHODS AND MATERIAL. The work is based on the analysis of the results of treatment of 31 patients with Fournier’s gangrene aged 32 to 82 years. In 19 (61.3 %) patients, the most probable nosological causes of Fournier’s gangrene were diseases of the anorectal zone, in 10 – pathology of the urogenital sphere. In 2 patients, Fournier’s gangrene developed as a result of a closed injury (1) and a gunshot wound (1) of the perineum and scrotum. A limited (slowly progressing) form of the disease was observed in 18 (58.1 %) patients, a common form with a lightning (9) and rapidly progressing (4) course – in 13 (41.9 %). 6 (19.3 %) patients suffered from diabetes mellitus of varying severity. In all patients, the clinical manifestations of the disease and laboratory parameters were characterized by the phenomena of generalized surgical infection with signs of systemic inflammatory response syndrome and endotoxicosis. In 93.5 % of patients, causative microflora was represented by various associations of both facultative-anaerobic and obligateaerobic gram-negative and obligate-facultative anaerobic gram-positive microorganisms. The growth of anaerobic gramnegative non-clostridial flora was also obtained.RESULTS. Out of 31 patients, 6 (19.3 %) patients died who had a common form of FG with a lightning and rapidly progressing clinical course in the format of systemic inflammatory response syndrome and systemic endotoxicosis with an outcome in organ-system dysfunction. The causes of death were: septic shock (in 1), progressive systemic endotoxicosis (sepsis) with the outcome of multiple organ failure (in 3) and pulmonary embolism (in 2).CONCLUSION. Multidisciplinary approach to solving organizational and therapeutic and tactical tasks with the participation of doctors of related specialties, active surgical tactics in the format of «aggressive surgery», providing for the widest possible excision of necrotic and non-viable tissues, performed in combination with programmed (stage-by-stage) sanitation necrectomy, pathogenetically justified correction of violations of the homeostasis system, rational antibacterial therapy, a comprehensive system of local wound treatment and plastic replacement of lost integumentary tissues are priority ways to optimize the results of treatment of patients with Fournier’s gangrene.

Post surgery mucor recurrence in COVID-19 associated mucormycosis patients of a tertiary care centre

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Together with COVID-19 infection, we saw an outbreak of COVID associated mucormycosis (CAM). These patients were treated with antifungals, aggressive surgery, control of diabetes and other predisposing factors. But as demand increased, there was shortage of antifungals. So patients underwent relapses. The aim of study was to evaluate the causes and relevant factors predisposing to recurrence and tools used to evaluate recurrence and extent of disease in relation to primary disease.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Prospective study of 160 CAM patients who were discharged successfully after surgery and kept under regular follow up by endoscopy, CRP, blood sugar monitoring.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Our study of 160 follow up cases of CAM in whom 21 patients had recurrence. There were 18 males and 3 females. The most common affected was between 50-60 years. 67% of recurrent cases had poor diabetic control, 81% suspicious of recurrence in endoscopy, 86% showed rising trend in CRP (&amp;gt;5 mg/dl). These patients were further evaluated with radiological investigations like MRI and CBCT (cone beam CT). MRI detected recurrence in 38% whereas CBCT detected 62%. Most common site of recurrence was maxilla. All recurrent cases underwent surgical debridement and were given 5 gm of liposomal amphotericin.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Mucormycosis is an invasive fungal disease. COVID patients in whom immunological status are altered, diabetic or immunocompromised should be kept under surveillence by endoscopy, CRP and blood sugar monitoring. Though CAM patients are treated with surgery and antifungals, they should be under regular follow up for more than 6 months. Diabetic control helps in curbing the rapid spread of CAM. Suspected cases should undergo radiological investigations like MRI and CBCT. Recurrent/residual disease of mucormycosis can be tackled and treated successfully.&lt;/p&gt;

A SPECULATED PLEOMORPHIC ADENOMA OF PAROTID TURNS OUT TO BE A SPINDLE CELL LIPOMA

Spindle cell lipoma is a rare benign adipocytic tumour which compromises about 1.5 % of the lipomatous tumour.It is a slow growing tumour most frequently located in upper back and neck with male predominance. Less frequently the tumour may occur in unexpected sites.A 43 year old male patient with history of right sided ,painless, indolent cheek mass. Clinical examination revealed a soft,non tender mass in the parotid region on right side. MRI scan shows lesion arising from tail of right parotid abutting right masseter muscle probably warthin tumor.Fine needle aspiration showed occasional epithelial cells with spindle cells. Case was proceeded with superficial parotidectomy. Grossly there was a well encapsulated mass of size 3.5 cm adherent to the adjacent parotid gland.Histopathology showed mature adipocytes in fibromyxoid stroma with spindle cell suggesting spindle cell lipoma.Spindle cell lipoma,a benign lipomatous tumour usually arises from the shoulder, upper back. These lesions can also arise from atypical sites causing diagnostic challenges. These tumours have to be differentiated from malignant tumours which may require aggressive surgery, while spindle cell lipoma itself is curative by a simple excision.This requires awareness of this entity by both surgeons and pathologists to aim for a proper management .