Ten-year clinical outcome, toxicity and compliance of dose-dense sequential adjuvant administration of cyclophosphamide & epirubicin followed by docetaxel in patients with early breast cancer: A hellenic cooperative oncology group observational study (HE 10/10) with concurrent investigation of significance of tumor infiltrating lymphocytes

BACKGROUND

Dose-dense sequential (dds) chemotherapy has changed the clinical outcome of patients with early breast cancer (BC). To investigate the impact of dose intensity (DI) in the adjuvant setting of BC, this observational trial (HE 10/10) was conducted assessing the long-term survival outcome, safety and toxicity of a currently widely used chemotherapeutic regimen. In addition, the prognostic significance of tumor infiltrating lymphocytes (TILs) and infiltrating CD8+ lymphocytes were also evaluated in the same cohort.

PATIENTS AND METHODS

Totally, 1054 patients were prospectively enrolled in the current study with 1024 patients being eligible, while adequate tissue was available for 596 of them. TILs, CD8+ lymphocytes in intratumoral areas in contact with malignant cells (iCD8), CD8+ lymphocytes in tumor stroma (sCD8) as well as the total number of CD8+ lymphocytes within the tumor area (total CD8) were assessed by immunohistochemistry.

RESULTS

Within a median follow-up of 125.18 months, a total of 200 disease-free survival (DFS) events (19.5%) were reported. Importantly, the 10-year DFS and OS rates were 78.4% (95% CI 75.0-81.5) and 81.7% (95% CI 79.0-84.1), respectively. Interestingly, higher CD8+ T cells as well as TILs in the tumor microenvironment were associated with an improved long-term survival outcome.

CONCLUSIONS

In conclusion, this study confirms the significance of dds adjuvant chemotherapeutic regimen in terms of long-term survival outcome, safety and toxicity as well as the prognostic significance of TILs and infiltrating CD8+ lymphocytes in BC patients with early-stage disease.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Undifferentiated - Dedifferentiated endometrial carcinoma; the reappearance of an old friend with insights into the new data

Endometrial carcinoma is a common malignancy in women and shows increasing incidence. Except for its two main pathogenetic types I and II, the continuing evolution on molecular genetics have led to a new classification system (TCGA), that includes four main molecular subtypes: i) POLE-mutant (ultramutated), ii) hypermutated (MSI), iii) copy-number low / MSS (p53wt) and iv) copy-number high / serous-like (p53mut). The undifferentiated and dedifferentiated endometrial carcinomas are rare and clinically aggressive variants, comprising about 10% of the high-grade endometrial carcinomas and 2% of the endometrial carcinomas in general. Until recently, they were under-recognized and not fully described morphologically and immunohistochemically / molecularly. Their recognition diagnostically is crucial because of their poor prognosis; approximately 40% of patients with these subtypes will die within 0.5-20 months after diagnosis, so additional therapeutic strategies are important for an effective management. Because of their rarity, the responsiveness to other than conventional treatment, such as immunotherapy, has not been sufficiently investigated yet. The aim of this review is to provide an update on the knowledge about these two uncommon subtypes according to the current literature.

All you need to know about gastrinoma today | Gastrinoma and Zollinger-Ellison syndrome: A thorough update

Zollinger-Ellison syndrome (ZES) is a distinct syndrome characterized by hyperchlorhydria-induced peptic ulcer disease and chronic diarrhea. It is the result of a gastrin-excess state caused by a duodenal or pancreatic neuroendocrine tumor referred to as gastrinoma. This gastrin-secreting neuroendocrine tumor is usually sporadic in nature, or part of multiple endocrine neoplasia type 1 syndrome. The high rate of malignancy associated with gastrinomas substantiates the need for early diagnosis. In order to diagnose ZES with laboratory tests, patients under antacid medication are required to stay off proton pump inhibitors for at least one week and H2 receptor antagonists for 48 h. Fasting serum gastrin level measurement serves as an initial and fundamental diagnostic test, boasting a sensitivity of 99%. Gastrinoma patients will present with a gastrin level greater than 100 pg/mL, while a serum gastrin level higher than 1000 pg/mL, in the presence of gastric pH <2, is considered diagnostic. Since more common causes of hypergastrinemia exist in the setting of hypochlorhydria, ruling those out should precede ZES consideration. Such causes include atrophic gastritis, Helicobacter pylori (H. pylori)-associated pangastritis, renal failure, vagotomy, gastric outlet obstruction and retained antrum syndrome. The secretin stimulation test and the calcium gluconate injection test represent classic adjuvant diagnostic techniques, while alternative approaches are currently being introduced and evaluated. Specifically, the secretin stimulation test aids in differentiating ZES cases from other hypergastrinemic states. Its principle is based on secretin stimulation of gastrinoma cells to secrete gastrin, while inhibiting normal G cells. The rapid intravenous infusion of 4 μg/kg secretin over 1 min is followed by gastrin level evaluation at specific intervals post-infusion. Localization of the primary tumor and its metastases is the next diagnostic step when gastrinoma-associated ZES is either suspected or biochemically confirmed. Endoscopic ultrasound has showcased sensitivity as high as 83% for pancreatic gastrinomas and is considered the primary modality in such cases, although its tumor detection rates are substantially lower in duodenal lesions. Gallium-68 radiotracers, especially DOTATOC with positron emission tomography, are currently setting the standard in tumor localization, enhancing traditional imaging techniques and showcasing high sensitivity and specificity. Although gastrinomas have been reported in various anatomic locations, the vast majority arise in a specific site named the "gastrinoma triangle", involving parts of the duodenum, pancreas and extra-hepatic biliary system. Proton pump inhibitors serve as the cornerstone of symptomatic ZES treatment. Surgery is routinely performed in localized sporadic ZES, irrespective of imaging results. ZES in multiple endocrine neoplasia type 1 requires work-up for evaluation and treatment of hyperparathyroidism, while surgery might be an option for selected cases. In cases of advanced and metastatic disease, there is a variety of potential treatments, ranging for somatostatin analogs to chemotherapeutic drugs, liver-directed therapies and liver transplantation, while neither hepatic metastases, nor locally invasive disease necessarily preclude surgical management. This article thoroughly and critically reviews available literature and provides an extensive and multidimensional overview of ZES, along with current controversies regarding management of this disease.

The Prognostic Role of GLIM Criteria in Postoperative Outcomes after Upper Gastrointestinal Cancer Surgery: A Meta-Analysis of Observational Studies

Oncologic patients often suffer from malnutrition, which might negatively affect treatment outcomes. Global Leadership Initiative on Malnutrition (GLIM)-based malnutrition is associated with short- and long-term outcomes in cancer patients. The aim of the current meta-analysis was to determine the impact of GLIM-defined malnutrition on postoperative complications and survival in esophageal and gastric cancer patients. A systematic search was conducted to identify studies published until February 2022 that assessed the association between GLIM criteria and short- and long-term outcomes in esophageal and gastric cancer patients. We included seven observational studies reporting on a total of 3662 patients with esophageal and gastric cancer. GLIM-defined malnutrition was associated with increased overall complications (pooled HR 2.58, 95% CI 1.45-4.59, p = 0.001). Malnutrition was significantly associated with decreased overall survival (pooled HR 1.63, 95% CI 1.18-1.84, p = 0.003) as well as with decreased disease-free survival (pooled HR 1.78, 95% CI 1.36-2.33, p < 0.0001). GLIM-based malnutrition was associated with an increased risk for developing postoperative complications and impaired survival of esophageal and gastric cancer patients. Our findings support the use of GLIM criteria in clinical practice as a relatively simple and reliable tool for assessing the nutritional status of oncologic patients.

Removal of microfiber in vertical flow constructed wetlands treating greywater

Nature-based solutions such as constructed wetlands (CW) are considered as a sustainable, green technology for greywater treatment. However, their efficiency to remove microplastics is not well-known even though greywater is considered as a significant source of microfiber pollution. In this study, the removal of fiber microplastics from greywater using a vertical flow constructed wetland (VFCW) was investigated. For the purposes of this study, an experimental wetland was constructed, planted with the flowering plant Zantedeschia aethiopica and filled with a substrate made of sand/gravel of several sizes. The system's performance was monitored for five months during which it received real laundry wastewater. Promising results were obtained showing the significant removal of microfibers from the influent (> 95 %). Moreover, the ability of the system to remove microfibers from laundry wastewater was not significantly affected from the hydraulic loading rate (HLR) applied. The average microfibers concentration decreased from 71 ± 25 microparticles/L in the influent to 1 ± 1 microparticles/L in the effluent of VFCW when an HLR of 63.7 mm/d was applied. High removal efficiencies were also observed for COD and turbidity (93 % and 94 %, respectively). Thus, the results indicate a significant improvement in the overall quality of laundry wastewater due to the use of the VFCW.

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND

The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not.

METHODS

Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not.

RESULTS

A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001].

CONCLUSIONS

The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.

Surgical management of familial pancreatic cancer: a systematic review of the literature

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is the third most common cause of cancer-related mortality. The fact that the vast majority of patients with PDAC are diagnosed at an advanced stage highlights the need of early diagnosis. As hereditary factors are associated with approximately 5% of all PDAC cases, a screening programme to these high-risk individuals (HRI) has been proposed. The aim of screening methods is to identify selected group of patients with morphological abnormalities at an early stage, in order to be treated promptly. In this study, we evaluate the surgical outcomes and the appropriateness of pancreatic resection in HRIs who were selected for screening.

METHODS

A systematic literature search of the PubMed, Embase, and Cochrane databases was performed. The clinicopathological features were recorded and evaluated.

RESULTS

Six studies were selected for data collection. A total number of 77 patients were identified. Twenty-one patients had a germline mutation, with CDKN2A being the most prominent one (15.6%). Distal pancreatectomy was the most common surgical procedure (42.8%), followed by pancreaticoduodenectomy (33.8%). The mean disease-free survival was 23.6 months and tumour recurrence occurred in 9 patients (11.7%). Disease-specific mortality was 17.8%, while overall mortality was 19.5%. The most frequently reported postoperative diagnosis was PDAC (28 cases, 38.9%), followed by IPMN (23 cases, 31.9%), whereas high-grade PanIN lesions were found in 13 patients (18.1%).

CONCLUSION

High-risk individuals for pancreatic cancer, who are eventually operated may have a relatively uneventful postoperative course, however the oncological outcomes are comparable to the general population.

Histological diversity of anti-PD1-induced colitis

AIM

Histological data on anti-PD1-associated colitis are limited, while the colitis subtypes are still not clearly defined and different terms are being used. The aim of the study was to explore the histopathology of anti-PD1-induced colitis.

METHODS AND RESULTS

Colonic biopsies from 9 patients under anti-PD1 agents presenting diarrhea were examined. Histological evaluation revealed colitis of mild to moderate severity in almost all cases. Four distinct dominant histological patterns were identified with nearly the same incidence: Ulcerative colitis (UC)-like (n=2), GVHD-like (n=2), collagenous-like (n=3) and a mixed colitis pattern combining features of microscopic and UC-like colitis (n=2). The latter was additionally characterized by high crypt epithelium apoptosis and cryptitis with mixed inflammatory infiltrate. Thickening of the subepithelial band of collagen, detachment of the surface epithelium and increased apoptosis of the crypt epithelium were commonly encountered features, irrespective of colitis subtype. CD4/CD8 ratio was lower in the "combined" and higher in the GVHD-like subtype.

CONCLUSIONS

Anti-PD1-induced colitis is expressed by different patterns of injury which share distinct histological hallmarks harboring diagnostic value, while a "combined" colitis subtype is being established. The histological alterations are indicative of mucosa barrier damage after antΙ-PD1 treatment and its participation in the pathogenetic process.

Identification and Biopsy of Sentinel Lymph Node in Early-Stage Cervical Carcinoma: Diagnostic Accuracy and Clinical Utility

Background Due to the subsequent complications of pelvic lymphadenectomy in patients with early-stage cervical cancer, the sentinel lymph node (SLN) technique has been increasingly employed. This study aimed to investigate the detectability of SLN using methylene blue and explore the diagnostic accuracy of SLN biopsy. Methodology A study was conducted from September 2015 to August 2018 and included 90 women with cervical cancer, FIGO (International Federation of Gynecology and Obstetrics-2009) stage IA1-IIA1. Methylene blue was injected intracervically. Any detected dyed nodes were sent for frozen section biopsy, followed by bilateral pelvic lymphadenectomy. The predictive ability of SLN was evaluated in statistical terms after comparison of intraoperative biopsy and final histopathology. Results The sensitivity, specificity, false-negative rate, positive predictive value, and negative predictive value (NPV) were 55.6%, 95.1%, 4.9%, 55.6%, and 95.1%, respectively. The SLN performance in patients with tumor size ≤2.2 cm, negative lymphovascular space involvement, and depth of stromal invasion ≤5 mm was superior (sensitivity 100%, specificity 93.5%, NPV 100%). Conclusions The SLN technique with blue dye alone is a feasible and adequate alternative to systematic lymphadenectomy in early-stage cervical cancer in selected patients, given that a strict algorithm is applied.

Bochdalek hernias in the adult population: a systematic review of the literature

BACKGROUND

Bochdalek hernia (BH) is characterized by the protrusion of viscera into thorax through the posterolateral section of the diaphragm. The aim of this study was to systematically review current literature concerning Bochdalek hernias in adults and elucidate their clinical characteristics and preferable treatment approach.

METHODS

A search of PubMed and Cochrane bibliographical databases for studies regarding BHs was conducted (last search: 31st March 2021).

RESULTS

Predefined inclusion criteria were met by 173 articles and concerned collectively 192 patients (50.5% males) with a mean age of 45.41 ± 20.26 years. Abdominal pain (62.0%) and pulmonary symptoms (41.1%) were the predominant symptomatology of included cases. BHs protruded mainly through the left side of the diaphragm (70.7%), with large intestine (42.7%) and stomach (37.1%) being the most commonly herniated abdominal organs. Most patients (53.8%) underwent an open surgical approach, while abdominal approach was preferred (64.8%). to the thoracic one. Thirty-day postoperative complication were encountered at 21.5% of patients, while 30-day mortality reached 4.4%.

CONCLUSION

BH is an extremely rare type of congenital diaphragmatic hernia. It rarely concerns adults, and it manifests with vague gastrointestinal or pulmonary symptoms. Surgical approach is the preferred method for their management with open procedures being preferable at emergency cases, while minimal invasive approach necessitates experienced centers. Further research is needed in order to clarify their true incidence and optimal therapeutic strategy.

mRNA expression of specific HER ligands and their association with clinical outcome in patients with metastatic breast cancer treated with trastuzumab

Prognostic and predictive biomarkers are being studied for the diagnosis and treatment of breast cancer. The present study retrospectively assessed the mRNA expression of HER family receptor ligands and of other potential prognostic biomarkers and their association with time to progression (TTP), survival and clinicopathological characteristics in patients with metastatic breast cancer (MBC) treated with trastuzumab. A total of 145 tumour tissue samples were analysed. mRNA expression analysis of the transcripts of interest was performed and the association of these markers with selected clinicopathological parameters was examined. HER2 status was centrally re-evaluated. Only 67.6% of patients were truly HER2-positive according to the central HER2 re-evaluation. Heparin binding epidermal growth factor (EGF)-like growth factor, transforming growth factor β1 (TGFB1) and thyroid hormone receptor α (THRA) mRNA expression was higher in HER2-positive patients (P=0.026, P<0.001 and P<0.001). Insulin-like growth factor binding protein 4 was correlated with retinoic acid receptor α, TGFB1 and THRA (rho=0.45, rho=0.60 and rho=0.45). In HER2-positive patients, high neuregulin 1 and high betacellulin were unfavourable factors for TTP [hazard ratio (HR) = 1.78, P=0.040 and HR=2.00, P=0.043, respectively]. In patients with de novo MBC, high EGF expression was associated with a non-significant prolongation of TTP (HR=0.52, P=0.080) and significantly longer survival (HR=0.40, P=0.020). The present study examined clinical and biological implications of specific genes and it was concluded that their expression has an impact on the outcome of trastuzumab-treated patients with MBC.

A novel tool for visualization and detection of pancreatic neuroendocrine tumours. A 'fluorescent' world is calling for exploration?

AIM OF THE STUDY

Pancreatic neuroendocrine tumours (pNETs) are rare tumours with a propensity to metastasize. Physicians frequently face a huge clinical challenge during the localization of these lesions. The aim of this study is to investigate whether fluorescence-guided localization techniques with indocyanine green (ICG) can be utilized as a detection tool in pNETs, along with any other clinical implications of this technique.

MATERIAL AND METHODS

A thorough literature search in PubMed and Google Scholar, under the terms 'ICG OR Indocyanine OR Fluorescence AND Neuroendocrine' until 31 June 2021, regarding the utilization of indocyanine-fluorescence in localization of pancreatic neuroendocrine, was conducted by the authors, and the associated results are presented.

RESULTS

Indocyanine fluorescence imaging may facilitate the efforts of surgeons to identify occult pancreatic neuroendocrine lesions, assisting them in the identification of resection margins and delineation of the surgical anatomy when it is difficult to clarify.

CONCLUSIONS

Indocyanine-fluorescence imaging might play a pivotal role in pancreatic surgery in terms of localization for neuroendocrine tumours. However, further large-scale clinical studies are needed to assess the absolute indications and optimal use of this technique.

Nonalcoholic fatty liver disease: The role of quercetin and its therapeutic implications

Nonalcoholic fatty liver disease (NAFLD) is the most common form of chronic liver disease, affecting almost one-third of the general population and 75% of obese patients with type 2 diabetes. The aim of this article is to review the current evidence concerning the role of quercetin, a natural compound and flavonoid, and its possible therapeutic effects on this modern-day disease. Despite the fact that the exact pathophysiological mechanisms through which quercetin has a hepatoprotective effect on NAFLD are still not fully elucidated, this review clearly demonstrates that this flavonoid has potent antioxidative stress action and inhibitory effects on hepatocyte apoptosis, inflammation, and generation of reactive oxygen species, factors which are linked to the development of the disease. NAFLD is closely associated with increased dietary fat consumption, especially in Western countries. The hepatoprotective effect of quercetin against NAFLD merits serious consideration and further validation by future studies.

A personalized approach to pancreatic ductal adenocarcinoma and its application in surgical practice

Pancreatic duct adenocarcinoma is an aggressive tumor which constitutes the fourth leading cause of cancer-related mortality in the USA. Despite the fact that surgery is an integral part of treatment, 5-year survival rates remain unfavorable, partly because of the complex genetic background, delayed diagnosis and also the absence of effective therapeutic approaches. To optimize surgery's results in recent years, the use of patients' genetic profile has been implemented through classification into subtypes; subtypes based on mutations which could efficiently lead oncologists to the path of targeted novel neoadjuvant regimens. This approach aims to achieve the most effective selection of patients undergoing surgery, to increase the number of potentially resectable tumors and also control micro-metastases, aiming to extend overall survival.

Measurement and calculation of radionuclide concentration ratios from soil to grass in semi-natural terrestrial habitats in Greece

The results of the measurements of radionuclide transfer from soil to vegetation (Poaceae spp.) that conducted during 2010-2014, in free-ranged grazing regions in Greece, are presented in this work. The specific activities of ¹³⁷Cs, ²²⁶Ra, ²²⁸Ra and ²²⁸Th radionuclides were measured and the activity concentrations were calculated in samples of soil and grass obtained from several studied regions in Greece. The respective soil-to-plant radionuclide transfer parameters (as Concentration Ratio) were calculated and the results were analyzed in terms of spatial deviation caused by the different climate type among the studied regions, provided that the same plant and soil types are studied. The Concentration Ratios ranged from 0.02 to 2.5 for ¹³⁷Cs, 0.01 to 0.7 for ²²⁶Ra, from 0.07 to 1.1 for ²²⁸Ra, and, from 0.08 to 0.17 for ²²⁸Th. Although, the concentration ratios of the primordial radionuclides show some consistency among the different regions, significant differences are observed for ¹³⁷Cs, which may be particularly attributed to the different climatic types (according to the Koppen-Geiger climate classification) that govern these regions.

Chyle leak after major pancreatic surgery. Is this an underestimated complication? A narrative review of the literature

PURPOSE

Postoperative chyle leak, termed 'chylous ascites', is a rare complication with a reported frequency of only one in 20464 abdominal operations. The purpose of this study was to summarize the available scientific data reviewing the most relevant studies for this type of postoperative complication after pancreatic surgery, highlighting at the same time the necessity for pancreatic surgeons to retain a high level of clinical suspicion for the early diagnosis and its therapeutic management.

METHODS

A thorough literature search in Pubmed and Google Scholar, under the terms' chylous ascites OR chyle leak AND pancreas OR pancreatic', since the year of inception until 19th of February 2021 was conducted by the authors and the associated results are presented in this narrative review.

RESULTS

Chyle leak is a rare complication following pancreatic surgery. Patients may suffer from exudative enteropathy and malnutrition leading to repeated infections and impaired wound healing or even death secondary to sepsis. Several studies have highlighted the issue of increased hospital stay, while others failed to reach statistical significance as far as hospital stay or survival are concerned. Researchers found that patients with diffuse chyle leak tended to have a worse 3-year survival rate (18.8%), which can be attributed to postoperative complications and early demise due to immunosuppression associated with the leak, or delayed adjuvant chemotherapy Conclusion: Further clinical research is needed to enhance prevention, diagnosis, treatment and long-term prognosis of this relevant surgical problem that shows trends of increase due to the great number of major operations which are performed nowadays.

Determination and mapping of the spatial distribution of cesium-137 in the terrestrial environment of Greece, over a period of 28 years (1998 to 2015)

In this study, we are applying the GIS techniques in order to record the data that have been collected for cesium-137, over the for the period 1998 to 2015, for the terrestrial environment in Greece. Following the Chernobyl Nuclear Power Plant (CNPP) accident in 1986, extended fieldwork was conducted for the determination of cesium-137 concentrations in the terrestrial environment. In 2011, in the light of the Fukushima Daiichi Nuclear Power Plant (FDNPP) accident, new campaigns were organized in order to assess the variation in cesium-137 activity concentrations. The measured data, combined with data taken from the databases of the Environmental Radioactivity Laboratory (NCSR'Demokritos', in Athens, Greece), as well as, from the European Atlas of Cesium Deposition on Europe, are being used for the spatial distribution analysis of cesium-137 in the country. Furthermore, are used for the temporal analysis of this radionuclide in a long-term basis. Moreover, we are using the ERICA Assessment Tool for the calculation of the dose rate that the studied organisms (plants of Poaceae spp. and mammals of Bovidae spp.) receive due to the exposure to cesium-137. All gathered information provides us with thematic maps, designed through the GIS techniques, that allow for an appropriate representation of cesium-137 presence in the country nowadays. This study provides an insightful view of the behavior of this anthropogenic radionuclide that is useful for future research in order to elucidate its behavior in long-term periods. The knowledge of the environmental fate of radionuclides is important because it contributes to the projection of long-term risks resulting from radionuclide releases, as well as, for the selection of cost-effective remediation strategies. Furthermore, it provides the opportunity to conduct a comprehensive risk assessment in the region, as the studied organisms were exposed to low-level ionizing radiation. But, as it was shown, on the level of ecosystem, no significant impact was estimated. However, regarding the future objectives, further consideration of the exposure levels should be considered while taking also into account the exposure to natural and background radiation and the exposure to spontaneous emission of anthropogenic radionuclides, especially if we want to consider the eventual effects of protracted low-level ionising radiation on the various levels of life's organization.

Colon Perforation in a 22-year-old Male with Bartter's Syndrome, Systemic Lupus Erythematosus and Leishmaniasis

Bartter's syndrome (BS) is an inherited renal tubular disorder characterized by hypochloremia, hypokalemia, metabolic alkalosis. Prognosis of Bartter's syndrome depends on the severity of the receptor dysfunction. In many cases the prognosis is good and patients are able to have fairly normal lives. Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of unknown cause that can affect virtually any organ of the body. The prognosis of SLE is quite variable, depending on the severity of the disease, the clinical course and organs involved. The last decades, there is a marked improvement in patient survival due to earlier diagnosis and treatment. Despite these improvements, patients with SLE still have higher mortality rates ranging from two to five times higher than that of the general population. Leishmaniasis is a disease caused by an intracellular protozoan parasite transmitted by the bite of a female phlebotomine sandfly. We report herein the case of a 22-year-old man with Bartter's syndrome (BS) and Systemic lupus erythematosus (SLE), who was hospitalized in the clinic of internal medicine because of Leishmaniasis. In the third day of his hospitalization the patient underwent Hartmann's operation for perforation located on descending colon. Management of patients with many severe diseases is very difficult for medical professionals.

Surgery for metachronous oligometastatic esophageal cancer: Is there enough evidence?

Esophageal cancer is the sixth most common cause of cancer-related mortality worldwide. Despite advances in diagnostic modalities and treatment options, five-year survival rates are below 20%. Esophagectomy with extended lymph node dissection is the mainstay of treatment. More than 50% of patients experience recurrence within 1-3 years postoperatively. Recurrent disease may present locoregionally at the site of anastomosis or as recurrence through lymphatic spread in lymph node basins, as hematogenic metastasis, or as a combination of these. The standard treatment of recurrence is currently predicated on systemic chemotherapy and/or radiotherapy. Recent evidence suggests that surgical treatment of metachronous oligometastatic disease may be prognostically advantageous over medical management alone. Given the considerably low response rates to chemoradiotherapy, many institutions have adopted surgical treatment strategies for oligo-recurrent disease on a case-by-case basis. The aim of this article is to review the current evidence on the role of surgical treatment for metachronous oligometastases from esophageal cancer.

A gelatinous veil inside the abdomen of a pancreatic cancer patient. What lies beneath it?

Chylous ascites following pancreatic surgery results from surgical damage to the cisterna chyli or tributaries, with an incidence in pancreatic surgery of 1.8%-11%. Usually, conservative treatment is effective.

A coordinated progression of progenitor cell states initiates urinary tract development

The kidney and upper urinary tract develop through reciprocal interactions between the ureteric bud and the surrounding mesenchyme. Ureteric bud branching forms the arborized collecting duct system of the kidney, while ureteric tips promote nephron formation from dedicated progenitor cells. While nephron progenitor cells are relatively well characterized, the origin of ureteric bud progenitors has received little attention so far. It is well established that the ureteric bud is induced from the nephric duct, an epithelial duct derived from the intermediate mesoderm of the embryo. However, the cell state transitions underlying the progression from intermediate mesoderm to nephric duct and ureteric bud remain unknown. Here we show that nephric duct morphogenesis results from the coordinated organization of four major progenitor cell populations. Using single cell RNA-seq and Cluster RNA-seq, we show that these progenitors emerge in time and space according to a stereotypical pattern. We identify the transcription factors Tfap2a/b and Gata3 as critical coordinators of this progenitor cell progression. This study provides a better understanding of the cellular origin of the renal collecting duct system and associated urinary tract developmental diseases, which may inform guided differentiation of functional kidney tissue.

Surgery for metachronous oligometastatic esophageal cancer: Is there enough evidence?

Esophageal cancer is the sixth most common cause of cancer-related mortality worldwide. Despite advances in diagnostic modalities and treatment options, five-year survival rates are below 20%. Esophagectomy with extended lymph node dissection is the mainstay of treatment. More than 50% of patients experience recurrence within 1-3 years postoperatively. Recurrent disease may present locoregionally at the site of anastomosis or as recurrence through lymphatic spread in lymph node basins, as hematogenic metastasis, or as a combination of these. The standard treatment of recurrence is currently predicated on systemic chemotherapy and/or radiotherapy. Recent evidence suggests that surgical treatment of metachronous oligometastatic disease may be prognostically advantageous over medical management alone. Given the considerably low response rates to chemoradiotherapy, many institutions have adopted surgical treatment strategies for oligo-recurrent disease on a case-by-case basis. The aim of this article is to review the current evidence on the role of surgical treatment for metachronous oligometastases from esophageal cancer.

Menstural function preservation treatment of a primary vaginal clear cell carcinoma with ovarian transposition and vaginal brachytherapy

Early stage vaginal carcinomas are typically treated with radical surgical procedures or radiation therapy. Both modalities impair the reproductive ability of the patients. We hereby report a case of menstrual function preservation in a 24-year-old patient with an early-stage primary vaginal clear cell carcinoma. We treated the patient with intravaginal brachytherapy after appropriate laparoscopic surgical staging and separate transposition of the ovaries and tubes. The patient is now 6 years without any evidence of disease. She reports minor. complaints during sexual intercourse, while her menstruation and hormonic profile are normal.

Eosinophilic Esophagitis and Achalasia: Two Distinct Nosologic Entities or a Possible Etiopathogenic Association?

BACKGROUND

Despite the fact that researchers have made significant progress in elucidating the pathophysiology of esophageal diseases, the understanding of esophageal motility alterations in patients with eosinophilic esophagitis (EoE) is in its infancy and current published medical literature remains rather scarce on this topic. A growing body of scientific data regarding associations between esophageal motor disorders, such as achalasia and EoE, exists nowadays.

SUMMARY

It seems that the association of EoE and achalasia does not constitute a cause and effect relationship, as it is not clear whether esophageal motility abnormalities are the result of EoE or vice versa. As such, there is no universally accepted treatment algorithm for patients presenting with both of these entities. Key Messages: The aim of this article is to review the existing data on achalasia-like motility disorders in patients with EoE, highlighting a possible association between these 2 esophageal disorders. Moreover, we seek to describe the clinical presentation in such cases, diagnostic modalities to be used, and current treatment strategies in patients suspected to suffer from both disorders.

UV-254 degradation of nicotine in natural waters and leachates produced from cigarette butts and heat-not-burn tobacco products

Nicotine is an important emerging contaminant widely detected in water resources. The main nicotine sources are human excretions from users and leaching from discarded tobacco product waste, which represents the most commonly littered item in urban areas and coasts. In this study, the UV₂₅₄ photolytical fate of nicotine in natural water and leachates produced from conventional cigarettes (CCs) and the new generation heat-not-burn (HnBs) tobacco products is examined for the first time. The effect of UV₂₅₄ irradiation on nicotine depletion in ultrapure water was initially studied. The reaction was pseudo first-order with respect to nicotine concentration at low concentrations and shifted to lower order at higher concentrations, an effect associated to absorption saturation. Although nicotine removal was fast, only 9.5% of the total organic carbon was removed after irradiation due to the formation of by-products. The chemical structures of six photo-products were derived by means of liquid and gas chromatography coupled to mass spectrometry. The photodegradation kinetics was found to depend on pH and faster kinetics were recorded when the monoprotonated form of nicotine was dominant (pH = 5-8). The presence of humic acids was found to slightly delay kinetics as they competed with nicotine for lamp irradiance, whereas the presence of salt had no effect on the direct photolysis of nicotine. Direct photolysis studies were also performed using natural waters. Compared to ultra-pure water, photodegradation was found to proceed slightly slower in river water, in similar kinetics in seawater, and relatively faster in rain water. The later was assumed to be due to the lower pH compared to the rest of the natural water tested. Leachates from used HnBs and smoked CCs were also submitted to UV₂₅₄ irradiation and direct photolysis was found to proceed fast despite the high complexity of these matrices. Nonetheless, the total organic carbon in the system remained the same after irradiation due to the abundance of organics and photo-products formed. We take advantage of the present investigations and report the leaching behavior of nicotine from HnBs and CCs. Among others, we found that in HnBs ~70% of the total and bioavailable nicotine content remains in the tobacco sticks after operation and this percentage drops to 15% in CCs due to the reduction in mass after smoking. This finding demonstrated the importance of properly disposing tobacco product waste to prevent nicotine leaching in water bodies.

Contribution of Histone Deacetylases in Prognosis and Therapeutic Management of Cholangiocarcinoma

Cholangiocarcinoma (CCA), a malignant tumor that occurs in the epithelium of the biliary tract, has a very poor prognosis because affected patients are frequently diagnosed at an advanced stage and recurrence after resection is common. Over the last two decades, our understanding of the molecular biology of this malignancy has expanded, and various studies have explored targeted therapy for CCA in order to improve patient survival. The histone acetylation/deacetylation equilibrium is affected in carcinogenesis, leading to altered chromatin structure and therefore changes in gene expression. Understanding the molecular identity of histone deacetylases (HDACs), their cellular interactions and potential role as anticancer agents will help us develop new therapeutic strategies for CCA-affected patients. Furthermore, HDAC inhibitors act on cellular stress response pathways and decrease cancer angiogenesis. Downregulation of pro-angiogenic genes such as vascular endothelial growth factor (VEGF), hypoxia inducible factor-1 (HIF-1), and endothelial nitric oxide synthase (eNOS) inhibit formation of new vessels and can negatively affect the metastatic process. Finally, recent clinical trials prove that administration of both HDAC inhibitors and DNA-targeting chemotherapeutic agents, such as topoisomerase inhibitors, DNA intercalating agents, inhibitors of DNA synthesis, covalently modifying DNA agents, and ionizing radiation, maximizes the anticancer effect by increasing the cytotoxic efficiency of a variety of DNA-damaging anticancer drugs. Therefore, combination therapy of classic chemotherapeutic drugs with HDAC inhibitors can act synergistically for the patients' benefit.

A mass mimicking pancreatic adenocarcinoma, should hepatobiliary surgeons keep it in mind? a case report

Isolated metastasis to pancreas from lung cancer is an extremely rare entity, usually reported in case series and case reports in the medical literature; estimated to account for up to 3-5% of all pancreatic lesions. Herein, we describe a case of a male patient suffering from metachronous metastatic lesion to the tail of the pancreas secondary to non small cell lung carcinoma treated 4 years prior to his presentation. The patient underwent pancreatic resection due to high clinical suspicion for the malignant nature of the mass, which was proved to be secondary lesion from its prior primary tumor. To the best of our insight this is one of the few reported cases of such type of pancreatic metastasis that may be misleading for hepatobiliary surgeons during preoperative evaluation.

The impact of COVID-19 on surgical training at a tertiary hospital in Greece: a 'hidden infectious enemy' for junior surgeons?

BACKGROUND

Soon after its appearance, the coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) became a pandemic, with over 111 million cases reported and 2.4 million deaths worldwide. Although the focus of public health systems must lie on patients' care and treatment, SARS-COV‑2 infection has also affected surgical trainees in their academic and professional development, causing significant disruption in all forms of their training.

METHODS

The aims of this study were firstly to assess the impact of SARS-CoV‑2 on core surgical training, regarding operative, educational and academic skills, as well as the general effect on psychological status and well-being of surgical trainees at a tertiary center in Greece. All core surgical trainees (17) in the general surgery department at the University Hospital of Patras were invited to participate in a voluntary anonymous survey via printed questionnaires.

RESULTS

Junior trainees and senior surgical trainees performed or assisted in almost 50% fewer cases in the COVID era when compared with the period reported before the virus. As far as courses, conferences and exams attended by trainees are concerned, a significant reduction in numbers (six vs 35) before and after the start of COVID-19 pandemic was apparent. In all, 10 (62.5%) trainees felt that their confidence in the operating theatre had been negatively impacted by the pandemic, while four (25%) trainees felt significant stress levels as a result of the national lockdown.

CONCLUSIONS

It is imperative for surgical educators to design and implement new alternative ways to assist surgical trainees in their education and also avoid their undertraining during the pandemic.

How do different histologic components of mixed endometrial carcinomas affect prognosis? Does it really matter?

The aim of this study is to evaluate and compare outcomes of patients with mixed and pure endometrial carcinomas (MEC). We reviewed data of patients with MEC, endometroid (EC), serous (SC), and clear cell (CC) carcinomas between 2002 and 2015. Overall survival (OS) and disease-free (DF) survival rates were evaluated, according to the percentage of histologic components. Clinicopathological variables and treatment strategies were assessed. Furthermore, χ ² tests were used to compare proportions and Kaplan-Meier curves to compare recurrence and survival. Sample consisted of 302 cases with mean age 66.3 years. Early-stage disease was recorded in EC compared with CC and SC. Adnexal involvement was more frequent in MEC compared with EC (p=0.043). Extra uterine metastasis was more frequent in the SC compared to the EC group, while lymphovascular space involvement was more frequent in the MEC and CC compared to the SC (p=0.001). EC had less omentum involvement compared to CC (p=0.035) and SC (p<0.001). Furthermore, cervical involvement was more frequent in CC compared to EC (p=0.011). Recurrence (p=0.265) and OS (p=0.533) were found to be similar in MEC compared with CC, SC, and EC. Moreover, recurrence and OS were similar between EC-CC and EC-SC. There were no differences in recurrence and survival in MEC with a type II component larger than 10% or 20% (p>0.05).

Juvenile Cystic Adenomyoma vs Blind Uterine Horn: Challenges in the Diagnosis and Surgical Management

BACKGROUND

Juvenile cystic adenomyomas (JCAs) are rare uterine lesions. Differential diagnosis might be difficult. We present the case of an adolescent who was diagnosed with JCA and was managed with laparoscopic excision.

CASE

A 14-year-old patient with complaint of menarche with excruciating dysmenorrhea, was diagnosed using magnetic resonance imaging with a uterine anomaly consisting of a normal right hemiuterus, and a left cystic lesion with surrounding hypotense myometrium. She was managed with laparoscopic excision of the left side, and uterine reconstruction. Histology was suggestive of JCA, associated with diffuse adenomyosis. Dysmenorrhea improved considerably after surgery.

SUMMARY AND CONCLUSION

Differential diagnosis between cystic uterine lesions relies on clinical, imaging, and perioperative clues that might assist in their formal classification. Doubt might still remain in some cases.

Retroflexion, a costless endoscopic maneuver, increases adenoma detection rate in the ascending colon

Background

Missed polyps during colonoscopy are considered an important factor for interval cancer appearance, especially in the ascending colon (AC). We evaluated the contribution of retroflexion to polyp and adenoma detection in the AC.

Methods

This prospective observational study included consecutive patients who underwent a complete colonoscopy between 06/2017 and 06/2018. The AC was examined in 2 phases: the first included 2 forward views from the hepatic flexure to the cecum; the second involved a retroflexion in the cecum, inspection up to the hepatic flexure and reinsertion to the cecum.

Results

The study included 655 patients, 628 (95.88%) with successful retroflexion (mean age: 62.5±10.8 years, 332 male). Indications for colonoscopy were screening in 33.28%, follow up in 36.03%, and diagnostic assessment in 30.69%. In total, 286 polyps and 220 adenomas were detected in the AC. Phase 1 identified 119 adenomas, yielding an adenoma detection rate (ADR) in the AC of 14.2% (95% confidence interval [CI] 11.52-16.84%) while phase 2 identified 86 additional adenomas, improving the ADR in the AC to 22.75% (95%CI 19.54-25.96%; P<0.01). Adenoma miss rate was 39.1% (86/225) and per-patient adenoma miss rate was 11.15% (73/655). Retroflexion proved beneficial mainly in the upper third of the AC (odds ratio [OR] 4.29, 95%CI 1.84-11.56; P<0.01) and for small (<5 mm) adenomas (OR 1.61, 95%CI 1.02-2.56; P=0.04). Multivariate analysis showed that age >60 years, detection of adenomas in forward views and the indication “follow up” influenced ADR during retroflexion.

Conclusion

Retroflexion is a simple and safe maneuver that increases the ADR in the AC and should complete a second forward view.

An unusual cause of large bowel obstruction: are we aware of this?

Primary lymphomas of the colon account for 0.5% of all primary colon malignancies. Burkitt´s lymphoma is a B-cell lymphoma with aggressive clinical behavior. Herein, we describe a case of a male patient who presented with signs of large bowel obstruction, underwent surgery and found to suffer from Burkitt´s lymphoma of the ileocecal region. The histopathological examination was indicative for Burkitt´s lymphoma. To the best of our insight this is one of the few reported cases of such type of lymphoma in an adult patient presenting with bowel obstruction. Burkitt´s lymphoma is a rare malignancy in adults affecting gastrointestinal tract. It has a high proliferation potential and can rapidly progress to advanced disease. Early diagnosis is necessary to prevent complications and improve overall prognosis.

Total Laparoscopic Excision of an Altman Type IV Sacrococcygeal Teratoma with the Assistance of Intraoperative Transrectal Sonography

OBJECTIVE

To present the case of a young patient with an Altman type IV sacrococcygeal teratoma (Fig 1) managed exclusively with laparoscopy.

DESIGN

A step-by-step demonstration of the technique.

SETTING

A 24-year-old patient complaining of dysmenorrhea, deep dyspareunia, chronic constipation, dyschezia, and bladder atony was diagnosed with a 5-cm cystic tumor compressing the low rectum and overlying the left levator ani muscle.

INTERVENTIONS

Laparoscopic excision of the tumor. At laparoscopy, significant bilateral pelvic venous congestion was found. The left medial and lateral pararectal fossa and the rectovaginal space were developed to the level of the pelvic floor. Several branches of the left internal artery and vein were dissected. The left hypogastric nerve and deep hypogastric plexus were dissected in an effort to preserve ipsilateral autonomic nerve supply to the rectum. Owing to the tumor's soft consistency and dense adherence to the surrounding structures, transrectal sonography facilitated dissection, which was performed medially to the mesorectal fascia and anteriorly to the presacral fascia. The middle sacral artery and peripheral branches of the internal iliac vasculature supplying the tumor were ligated. Part of the left levator ani had to be excised. The rectum was injured during the effort to detach the tumor from its lateral wall. The injury was repaired laparoscopically. The cut edge of the levator ani was used as a flap to reinforce the repair.

CONCLUSION

Sacrococcygeal teratomas lying entirely in the pelvis (Altman type IV) are extremely rare [1,2]. Complete laparoscopic excision is challenging and potentially dangerous [3-5], but it is feasible with careful dissection.

Radiological risk assessment in the terrestrial ecosystem: comparative study of two software tools used for dose rate calculations

In this study, two software tools, namely the ERICA Assessment Tool and the RESRAD-BIOTA code, are used for the calculation of the radiological exposure of non-human organisms. For the purposes of the analysis, data retrieved from field studies are used. The site-specific measurements were performed on organisms (mammals-sheep and goats of Bovidae spp.) collected from free-ranged grazing regions in Greece. Plants (grass) of Poaceae spp. and soil samples were also collected from these regions. Natural radionuclides (²²⁶Ra, ²²⁸Ra, and ²²⁸Th) of lithogenic origin and ¹³⁷Cs, resulted from human activities (Chernobyl and Fukushima nuclear power plant accidents and global fallout), were detected in all samples. The measured activity concentrations were used as input to the two software tools, the ERICA Assessment Tool and the RESRAD-BIOTA code. The results of the simulations provided the external, internal, and total dose rates received by the organisms due to the exposure to the radionuclides. The assessments indicated that out of all detected radionuclides, ²²⁸Th is the main contributor to the external dose and ²²⁶Ra and ²²⁸Ra are the main contributors to the internal dose. The comparative analysis of the two tools revealed significant differences in the calculated doses. In fact, external and internal doses calculated by RESRAD-BIOTA are higher than the values calculated by the ERICA Tool, due to the dose conversion coefficients (DCCs) used for the dose calculation. RESRAD-BIOTA provides more conservative values, but ERICA Tool provides lower uncertainty due to the higher flexibility in the design of the phantom organism. On a risk assessment basis, there is no significant impact, due to organisms' exposure to radioactivity. However, further consideration of the exposure levels is required due to the potential effects of protracted low-level ionizing radiation on the various levels of life's organization.

Opposite Prognostic Impact of Single PTEN-loss and PIK3CA Mutations in Early High-risk Breast Cancer

BACKGROUND/AIM

PTEN-loss and PIK3CA mutations have been addressed as markers of PI3K activation in breast cancer. We evaluated these markers in early high-risk breast cancer (EBC) focusing on PTEN immunohistochemistry (IHC) issues, particularly in HER2-positive disease.

MATERIALS AND METHODS

We examined PTEN-loss and PIK3CA mutations in 1265 EBC patients treated with adjuvant chemotherapy within two clinical trials. Two different methods for the evaluation of PTEN IHC were used, one upfront binary (loss; no-loss) and the other initially multi-scale allowing for the classification of "grey zone" tumors with low and very low PTEN protein expression.

RESULTS

PTEN-loss (33.4% and 22.1%, depending on the IHC method) and PIK3CA mutations (29.6%) were associated with ER/PgR/HER2-negative and ER/PgR-positive disease, respectively. Concordance of the two IHC methods was moderate (Cohen's kappa 0.624). PTEN-loss discrepancy and intra-tumor heterogeneity concerned "grey zone" tumors that were prevalent among HER2-positive cancers. PTEN-loss independently conferred higher risk for relapse and death. Compared to single PIK3CA mutations,single PTEN-loss was independently associated with increased risk for relapse and death. Depending on the evaluation method, in HER2-positive cancer, PTEN-loss was without- or of marginal unfavorable prognostic significance.

CONCLUSION

In EBC, PTEN-loss is an independent predictor of poor outcome. When occurring singly, PTEN-loss and PIK3CA mutations have opposite prognostic impact. In HER2-positive disease, assessment of PTEN-loss by IHC appears unreliable and the marker is without clear prognostic significance.

Abdominal Radical Trachelectomy for Early-Stage Cervical Cancer During Pregnancy: A Provocative Surgical Approach. Overview of the Literature and a Single-Institute Experience

OBJECTIVE

Treatment of pregnancy complication due to malignancy of the cervix constitutes a great clinical challenge between optimal maternal therapy and fetal viability. Radical trachelectomy in early-stage cervical cancer during pregnancy instead of radical hysterectomy presents an alternative approach that can offer a satisfactory outcome for the mother and fetus.

MATERIALS AND METHODS-RESULTS

A literature search of articles in English has been performed. Until now, 28 women with cervical cancer, including 2 who were managed and treated in our institute, who underwent a radical trachelectomy during pregnancy have been reported. We overviewed a total of 13 abdominal trachelectomies, 13 vaginal trachelectomies, and 2 laparoscopic trachelectomies.

CONCLUSIONS

Radical trachelectomy can widen the therapeutic approach of early-stage cervical cancer in pregnant women who wish to preserve their pregnancy, providing a possibility of receiving the proper treatment with no delay.

Irreversible electroporation and sarcomas: where do we stand?

Sarcomas arise from uncontrolled cell growth in tissues of mesodermal origins, such as connective tissue, bone, cartilage, fat or muscle. Surgical resection is still considered the cornerstone in the treatment of sarcomas. However, in many cases where tumor is adjacent to vital structures like major vessels, other treatment modalities may be implemented. Irreversible electroporation (IRE), a new form of ablative technique has been introduced lately in the treatment of several types of sarcomas. Irreversible electroporation has shown promising results and survival improvement in primarily inoperable solid tumors and locally advanced cancers, including prostate, kidney, liver, bone and pancreatic cancers in close proximity to important structures. The aim of this review was to sum up the current knowledge and the future perspectives of the usage of IRE in the management of sarcomas. Our study indicates that IRE could possibly represent a potential therapeutic option in patients with advanced or metastatic sarcoma, when surgery is not indicated.

A type of neoplasia deadlier than gastric adenocarcinoma? Report of a case of primary gastric squamous cell carcinoma

Background

Primary gastric squamous cell carcinoma is an extremely rare malignancy with few case reports reported so far in the current medical literature. Its incidence varies between 0.04 and 0.07% of all gastric malignancies with a male predominance in the sixth decade of life. It has been found that this type of malignancy has a more aggressive behavior and associated poorer prognosis, when compared to gastric adenocarcinoma. Thus, the most appropriate management of this kind of neoplasia is still debatable due to the small number of reported cases.

Case presentation

We report the case of a 66-year-old man who underwent total gastrectomy with D2 lymphadenectomy for an ulcerative lesion in the fundus of the stomach that turned out to be primary gastric squamous cell carcinoma.

Conclusions

Upon confirmation of this specific malignancy, the affected patients should be enrolled in strict follow-up protocols after curative surgery, since the risk for metastasis is high. Physicians should maintain high clinical suspicion in order to diagnose these tumors at an early stage, along with the need to rule out any other possible primary sites of squamous malignancy.