The role of sentinel lymph node dissection in lobular breast cancer

Lobular breast cancer represents a rare histopathological subtype of this malignancy, being characterized by a particular way of lymphatic spread. Therefore, the most widely known property of this tumor is the one of skipping certain lymphatic groups. Due to this aspect, the benefits of sentinel node identification were considered to be controversial so far. The aim of the current paper is to discuss about the indications and contraindication of this procedure in lobular carcinoma of the breast.

Postoperative diaphragmatic herniation after cytoreductive surgery in advanced stage ovarian cancer

Ovarian cancer is frequently associated with upper abdominal involvement necessitating extensive resections at this level. In such cases a significant increase of the postoperative complications is to be expected, the most commonly encountered one being represented by pleural effusion. Another complication which is described less frequently but which is associated with higher risks is represented by upper abdominal herniation at the level of the thorax. The aim of this paper is to discuss the risk factors and the therapeutic strategies in such cases.

Is routine appendectomy justified in mucinous borderline ovarian cancer?

Mucinous borderline ovarian tumors represent up to one half of cases diagnosed with borderline lesions and are usually associated with favourable outcomes. When it comes to the therapeutic options in these cases, the initial trend was to adopt the same strategy as in cases presenting invasive mucinous lesions. However, studies conducted so far cam to demonstrate that the appendix presented tumoral infiltration in an extremely low number of cases especially if a normal macroscopical aspect was present and therefore routine appendectomy was no longer recommended. The aim of the current paper is to investigate in which cases appendectomy should still be part of the therapeutic strategy in mucinous borderline ovarian tumors.

Microvascular surgery for upper limb lymphedema treatment

Although the necessity of performing radical mastectomy has significantly decreased over the last decades there are still cases in which this procedure is required, predisposing the patient to the development of long-term complications such as upper limb lymphedema. Meanwhile, due to the increased implementation of indocyanine green usage, the rates of this complication have decreased, preservation of the lymphatic vessels of the arm being more and more possible. Even though, upper limb lymphedema can be still encountered, in such cases vascular surgical procedures such as lymphovenous anastomoses might be performed in order to treat this complication. This is a literature review regarding the usage and effectiveness of indocyanine green administration in the upper limb lymphedema treatment.

Is laparoscopic sclerotherapy justified in the management of endometriomas?

Endometriomas represent a common finding among women at fertile age and usually associated with pelvic pain, infertility, heavy menstrual periods and dyspareunia. For a long period of time surgical resection has been considered the golden standard in such cases. However, although resection aims to take off only the cyst, in certain cases a decrease of the ovarian reserve and secondarily, to a decrease of the fertility is observed. Due to this reason, attention was focused on creating other methods for cyst destroying without impeding the ovarian reserve. The aim of the current paper is to discuss about the effectiveness and safety of sclerotherapy as part of the therapeutic strategy for endometriomas.

Indocyanine green utility in prevention and treatment of upper limb lymphedema

Although screening tests have been widely implemented globally, there are still cases diagnosed with breast cancer in which radical mastectomy and axillary lymph node dissection remains the option of choice. In such cases significant alteration of the quality of life can occur especially in cases in which upper limb lymphedema develops. Therefore, attention was focused on determining the causes related to upper limb lymphedema as well as the therapeutic options in such cases. Special attention was given to the utility of indocyanine green for upper limb lymphatic preservation as well as for the utility of the method in treating this complication. This is a literature review regarding the possibilities of prevention and treatment of upper limb lymphedema by using indocyanine green.

Utility of indocyanine green in the administration of cytotoxic drugs in breast cancer patients

Indocyanine green has been widely introduced in breast cancer protocol for sentinel node detection, for upper limb lymphedema prevention and for breast reconstruction. However, more recent studies came to demonstrate that these particles can be also used in order to provide an efficient intraoperative detection of metastatic deposits as well as for a more targeted delivery of cytotoxic drugs. The current paper aims to investigate the mechanisms of action, the principles and the benefits of indocyanine green as a therapeutic tool, part of the medical oncologic treatment of breast cancer patients.

The Influence of the Preoperative Status on the Risk of Postoperative Complications After Cytoreductive Surgery for Advanced-stage Ovarian Cancer

BACKGROUND/AIM

The aim of this study was to analyze the influence of preoperative status on the risk of developing further postoperative complications after debulking surgery for advanced-stage ovarian cancer.

PATIENTS AND METHODS

A total of 80 consecutive patients submitted to surgery between 2014 and 2019 for advanced-stage ovarian cancer were retrospectively reviewed.

RESULTS

Among the 80 cases there were seven patients who developed serious postoperative complications requiring reintervention. Among these cases it seems that association of obesity, poor nutritional status (defined as a lower than 3.5 g/dl serum albumin level) and elderly age were significantly associated with the risk of developing further complications.

CONCLUSION

When selecting the candidates for debulking surgery for advanced-stage ovarian cancer attention should be focused on excluding cases presenting such preoperative risk factors in order to decrease the postoperative morbidity.

Utility of indocyanine green injection in patients with cervical cancer besides the identification of sentinel lymph node (Review)

Due to the wide introduction of screening tests, patients with neoplastic diseases of the uterine cervix trend to be diagnosed in early stages of the disease, and less invasive surgical procedures are needed in certain cases. In this respect, the technique of sentinel lymph node dissection has been widely implemented as part of the therapeutic strategy, indocyanine green (ICG) being one of the most reliable markers for sentinel lymph node detection. However, it seems that this agent is extremely useful in order to achieve better short-term and long-term results after cervical cancer surgery, due to its capacity to determine the uterine vascular perfusion in cases in which conservative treatment, such as trachelectomy, is performed, as well as to prevent and treat lower limb lymphedema. A literature review was conducted of the studies which focused on the role of ICG utility in cervical cancer patients besides sentinel lymph node detection, special focus was given to vascularization preservation and lower limb lymphedema prevention and treatment.

Upper Abdominal Resections as Part of Tertiary Cytoreduction for Relapsed Ovarian Cancer

BACKGROUND/AIM

The role of upper abdominal resection as part of debulking surgery for advanced-stage or relapsed ovarian cancer has been widely debated. The aim of this study was to investigate the safety and efficacy of upper abdominal resection as part of tertiary cytoreduction.

PATIENTS AND METHODS

Between 2005 and 2019, 11 cases presenting upper abdominal recurrences after surgically treated ovarian cancer were submitted to surgery with radical intent.

RESULTS

Complete debulking surgery was feasible in eight cases, optimal debulking was performed in two cases, while in one case a suboptimal resection was performed. The most commonly performed upper abdominal resections consisted of liver resection in seven cases, splenectomy in four cases, diaphragmatic resection in three cases, pancreatic tail resection in two cases and partial gastrectomy in another two cases. Postoperative complications were encountered in two cases, while postoperative mortality was null.

CONCLUSION

Extended upper abdominal resection can be safely performed in order to increase the chances of optimal debulking surgery at the time of tertiary cytoreduction.

Extended Pelvic Resections as Part of Secondary Cytoreduction for Relapsed Ovarian Adenocarcinoma

BACKGROUND/AIM

Ovarian cancer presents an aggressive tumor biology, a significant number of patients experiencing recurrent disease. The aim of this study was to examine the feasibility and effectiveness of secondary debulking surgery for relapsed ovarian cancer.

PATIENTS AND METHODS

Between 2014 and 2018, debulking surgery for relapsed ovarian cancer was performed in 40 cases.

RESULTS

Debulking surgery to no residual disease was achieved in 31 cases; among the remaining cases, an R1 resection was feasible in six cases, while in the remaining three cases an R2 resection was performed. The most commonly performed visceral resections were represented by rectosigmoidian resection, right colon resection, total or partial cystectomy and unilateral or bilateral ureteral resection. The early postoperative morbidity rate was 32.5% while the postoperative mortality rate was 2.5%.

CONCLUSION

Extended pelvic resections are feasible in patients with relapsed ovarian cancer and might be performed with acceptable rates of postoperative complications.

Pancreatoduodenectomy After Neoadjuvant Chemotherapy for Locally Advanced Pancreatic Cancer in the Presence of an Aberrant Right Hepatic Artery

BACKGROUND/AIM

Locally advanced pancreatic head cancer remains an aggressive malignancy with a low likelihood of achieving resectability after neoadjuvant chemotherapy. Resection is even more difficult if anatomical variations of the blood supply are present.

CASE REPORT

We present the case of a 62-year-old male diagnosed with locally advanced pancreatic cancer in the presence of an aberrant right hepatic artery originating from the superior mesenteric artery. After completing six cycles of neoadjuvant chemotherapy consisting of irinotecan and oxaliplatin, resectability was achieved, the patient being submitted to pancreatoduodenectomy. Intraoperatively, the presence of an aberrant right hepatic artery originating from the superior mesenteric artery was confirmed. The postoperative course was uneventful, the patient being discharged on the eight postoperative day, while the histopathological studies confirmed the negativity of the resection margins.

CONCLUSION

Resectability can be achieved after neoadjuvant chemotherapy for locally advanced pancreatic cancer. However, attention should be focused on the possibility of the presence of anatomical variations of the pancreatic and liver blood supply.

Risk Factors for Postoperative Complications After Vulvar Surgery

BACKGROUND/AIM

Although the trends of surgical treatment in vulvar cancer patients are towards less extended resections, a significant number of cases are still diagnosed with locally advanced diseases imposing performing extended resections. The aim of this paper is to identify the prognostic factors for the development of early postoperative complications following vulvar surgery.

PATIENTS AND METHODS

Between 2017 and 2019, 145 patients with vulvar cancer were submitted to surgery with a curative intent.

RESULTS

Among these cases there were 93 cases diagnosed with early stages of the disease and 52 cases diagnosed with advanced stages. The risk of postoperative complications was significantly influenced by: i) the stage of the disease, ii) the preoperative levels of serum albumin, iii) the status of the resection margins, iv) previous history of irradiation, v) length of hospital stay and vi) association of comorbidities.

CONCLUSION

Vulvar cancer surgery for locally advanced disease is still associated with high rates of postoperative complications, and an attentive selection of cases submitted to surgery is mandatory.

Right Upper Abdominal Resections in Advanced Stage Ovarian Cancer

BACKGROUND/AIM

The right upper abdominal involvement is frequently encountered in patients with advanced stage ovarian cancer. The aim of this paper is to study the safety and efficacy of extended resections at this level as well as to determine the sites of residual disease.

PATIENTS AND METHODS

Between January 2016 and December 2019, 26 patients submitted to right upper abdominal resections were identified.

RESULTS

Peritoneal stripping and full thickness resections were the most commonly performed resections (in 57% and 19% of cases, respectively), followed by capsular liver resection and atypical liver resection (in 30% and 23% of cases, respectively) while the most common sites where resection was incomplete were the liver pedicle and porta hepatis. Exceptionally, one case necessitated performing a pancreatoduodenectomy as part of debulking surgery. Postoperatively, two cases developed serious complications and required reintervention; however, the overall mortality was null.

CONCLUSION

Right upper abdominal resections seem to be feasible and effective in order to maximize the debulking effort with acceptable risks arising from perioperative complications.

Pelvic Exenteration for Locally Advanced and Relapsed Pelvic Malignancies - An Analysis of 100 Cases

BACKGROUND/AIM

Although pelvic exenteration is an aggressive surgical procedure, it remains almost the only curative solution for patients diagnosed with large pelvic malignancies.

PATIENTS AND METHODS

We present a series of 100 patients submitted to pelvic exenteration with curative intent.

RESULTS

The origin of the primary tumor was most commonly represented by cervical cancer, followed by, endometrial cancer, rectal cancer, ovarian cancer and vulvo-vaginal cancer. An R0 resection was confirmed in 68 cases, while the remaining 32 cases presented lateral positive resection margins or perineal positive margins. The postoperative morbidity rate was 37% while the mortality rate was 3%. As for the-long term outcomes, the median overall survival time was 38.7 months, being most significantly influenced by the origin of the primary tumor.

CONCLUSION

Although pelvic exenteration is still associated with an increased morbidity, an important improvement in the long-term survival can be achieved, especially if radical resection is feasible.

Pancreatoduodenectomy En Bloc With Vascular Resections in Borderline Resectable Pancreatic Cancer

BACKGROUND/AIM

Pancreatic cancer remains asymptomatic for a long period of time, being frequently diagnosed when vascular invasion is already present. Such cases are widely known as borderline lesions. The aim of this study was to identify the effectiveness of vascular resection in this subgroup of patients.

PATIENTS AND METHODS

Fifteen such cases were submitted to surgery with curative intent.

RESULTS

Eight cases were diagnosed with borderline resectable lesions with portal vein invasion and were submitted to per primam resection and seven cases were initially diagnosed with arterial invasion and had been initially submitted to neoadjuvant chemotherapy followed by resection. In all cases portal vein resection was needed while in other four cases association of superior mesenteric artery resection was performed. Postoperatively, five patients developed complications requiring reoperation, three of whom died at the end of the first postoperative month. The histopathological studies confirmed the completeness of resection in all cases.

CONCLUSION

Vascular resections in pancreatic cancer resections remain demanding procedures, and are reserved for cases in which a radical resection is feasible.

The Impact of the Preoperative Status on the Short-term Outcomes After Exenteration and Pelvic Reconstruction

BACKGROUND/AIM

The aim of this study was to analyse the influence of the preoperative status on the perioperative outcomes of patients submitted to pelvic reconstructions after exenteration.

MATERIALS AND METHODS

Between January 2017 and December 2018, pelvic exenteration was performed in 86 cases; patients were classified according to their age, nutritional status and association of reconstructive surgery.

RESULTS

The median age was 56 years, while the median level of serum albumin was 3.6 g/dl. Reconstructive surgery was more frequently performed in younger patients, while the rate of postoperative complications was similar between the two groups, while the rate of postoperative complications was significantly higher among cases with lower serum albumin levels.

CONCLUSION

Reconstructive surgery should be performed in selected patients. Elderly cases as well as those presenting a poorer nutritional status are at higher risk of developing postoperative complications.

The Risk of Para-Aortic Lymph Node Metastases in Apparent Early Stage Ovarian Cancer

Background and objectives: To identify the risk factors for para-aortic lymph node metastases in cases with presumed early stage ovarian cancer. Materials and methods: Between 2014 and 2019, 48 patients with apparent early stage ovarian cancer were submitted to surgery. In all cases, pelvic and para-aortic lymph node dissection was performed for staging purposes. Results: Among the 48 cases we identified nine cases with positive pelvic lymph nodes and 11 cases with positive para-aortic lymph nodes. The positivity of the retrieved lymph nodes was significantly correlated with the histopathological subtype represented by serous histology (p = 0.02), as well as with the degree of differentiation (p = 0.004). Conclusions: Patients with serous ovarian carcinomas in association with a poorer degree of differentiation are at risk of associated lymph node metastases even in presumed early stages of the disease. Therefore, lymph node dissection should be performed in such cases in order to provide adequate staging and tailoring of further treatment.

Superior Mesenteric and Portal Vein Reconstruction With Cadaveric Allograft During Pancreatoduodenectomy - A Case Report and Literature Review

BACKGROUND/AIM

During the last decade it has been widely demonstrated that venous involvement in pancreatic head cancer is not a sign of poor prognostic, while surgery with curative intent is feasible and with encouraging results. However, the location and extent of venous invasion can occasionally pose serious problems in terms of reconstruction. The aim of the paper is to describe a case in which total superior mesenteric and portal vein resection followed by reconstruction were successfully performed.

CASE REPORT

We present the case of a 74-year-old patient submitted to surgery for locally advanced pancreatic cancer invading the portal and superior mesenteric veins. Surgery consisting of pancreatoduodenectomy en bloc with portal vein and superior mesenteric vein resection was performed. The venous axis was reconstructed by using a venous cadaveric allograft originating from the external iliac vein. The postoperative outcome was favorable and the histopathological studies confirmed the local invasion of the resected venous structures.

CONCLUSION

The cadaveric venous allograft can be safely used in order to reconstruct the venous axis following extended vascular resections for pancreatic cancer.

Urinary Tract Resections as Part of Debulking Surgery for Locally Advanced Endometrial Stromal Sarcomas

BACKGROUND/AIM

Although very rare tumors, uterine sarcomas are extremely aggressive gynecologic malignancies being responsible for a significant number of gynecological cancer-related deaths. However, in such cases, it seems that cytoreductive surgery might increase the lifespan if debulking to no residual disease is achieved.

PATIENTS AND METHODS

We present a case series of three patients diagnosed with endometrial stromal sarcomas in which urinary tract resections were needed in order to maximize the debulking effort.

RESULTS

In all cases total hysterectomy with bilateral adnexectomy was performed; in the meantime, urinary tract resection was needed due to the local extension of the neoplastic disease and consisted of unilateral ureteral resection followed by reimplantation through ureteroneocystostomy in one case, bilateral ureteral resection en bloc with partial cystectomy and ureteral reimplantation in one case and total cystectomy with bilateral ureterectomy followed by cutaneous ostomy in the third case. Moreover, one case also necessitated rectosigmoidian resection followed by colorectal anastomosis. In all cases no residual disease was encountered at the end of the debulking surgery.

CONCLUSION

Urinary tract resections might be needed in order to maximize the debulking effort in patients presenting endometrial stromal sarcomas.

Anterior Pelvic Exenteration for Chemo-irradiated Non-diethylstilbestrol Exposed Clear Cell Vaginal Cancer

BACKGROUND/AIM

Clear cell vaginal adeno-carcinomas are rare tumors occurring in women which are usually treated by chemo radiotherapy with good outcomes. However, in certain cases, this treatment is not associated with complete response and a further surgery is needed.

CASE REPORT

We present the case of a 38-year-old patient diagnosed with stage IVA clear cell vaginal cancer who had been previously submitted to radio chemotherapy and in whom the lesion persisted after the oncological treatment; therefore, the patient was proposed for surgery with curative intent. The tumor was resected by performing an anterior pelvic exenteration with good outcomes, the patient being discharged in the seventh postoperative day. At one-year follow-up the patient remains free of recurrent disease.

CONCLUSION

Pelvic exenteration with curative intent might be the option of choice for persistent locally advanced clear cell vaginal cancer.

The Impact on the Long-term Outcomes of Hormonal Status After Hepatic Resection for Breast Cancer Liver Metastases

BACKGROUND/AIM

Breast cancer remains one of the most frequently encountered malignancies worldwide, which is in most cases diagnosed in early stages of disease. However, although surgery and adjuvant oncological treatment are performed with curative intent, a certain number of cases will develop distant metastases. In cases presenting oligometastatic disease, surgery might be tempted in order to maximize the benefit in terms of survival. The aim of this paper was to identify which cases could benefit most after liver resection for breast cancer liver metastases.

MATERIALS AND METHODS

The study included 67 patients submitted to surgery for breast cancer liver metastases between 2003 and 2017 in the "Dan Setlacec" Center of Gastrointestinal Diseases and Liver Transplantation, Fundeni Clinical Institute.

RESULTS

Patients diagnosed with hormone-positive breast tumors reported a significantly higher disease-free and overall survival after resection of the primary tumor. After resection for breast cancer liver metastases, patients presenting hormone receptors at the level of the metastatic sites also experienced a better outcome when compared to those in which hormonal receptors were absent. However, the difference was not statistically significant.

CONCLUSION

Liver resection for breast cancer liver metastases seems to be associated with the best outcomes in terms of survival in patients presenting positive hormonal receptors status.

Is there a place for liver transplantation in cases with unresectable central cholangiocarcinoma?

Central cholangiocarcinoma represents a very aggressive malignancy associated with poor survival rats especially due to the fact that most patients are diagnosed in advanced stages of the disease when curative resection is no longer feasible. In order to try improving the long-term outcomes of these patients, especially in unresectable cases liver transplantation has been proposed with promising results. This is a literature review of the largest studies focused on this subject. Cholangiocarcinomas remain aggressive tumors with poor outcomes whenever surgery with curative intent is not feasible. Currently, the largest experience accumulated consists of neoadjuvant external beam radiotherapy in association with beam radiation, 5 fluorouracil and capecitabine followed by orthotopic liver transplantation. Following this therapeutic protocol excellent long-term outcomes have been reported even if vascular involvement is present.

Successful Resection of a Non-functional Paraganglioma with Celiac Trunk Invasion Followed by Common Hepatic Artery Reimplantation - A Case Report and Literature Review

Paragangliomas, as well as phaeochromocytomas, are vascular neuroendocrine lesions that might be encountered between neck and pelvis. In certain cases, a preoperative diagnosis is difficult to be established, so resection might be needed whenever a suspect mass is discovered at the imaging studies. Moreover, there are cases in which resection and reconstruction of an important vascular structure might be imposed. In this case report a 59-year-old patient was investigated for upper abdominal pain with postprandial features and was diagnosed with a retroperitoneal tumor of 4/6/7cm invading the celiac trunk. The tumor was successfully resected and the common hepatic artery was reinserted in the celiac stump.

Spleno-pancreatectomy En Bloc with Parcelar Gastrectomy for Splenic Artery Aneurysm - A Case Report and Literature Review

Splenic artery aneurysms are common arterial lesions which might remain asymptomatic for a long period of time. In certain cases, these lesions might encounter a significant growth and might become symptomatic. Once diagnosed, a therapeutic strategy should be taken in consideration in order to avoid the apparition of life-threatening complications such as aneurysmal rupture. This is a case report of a 45-year-old patient diagnosed with a splenic artery aneurysm who was successfully submitted to an aneurysmal resection en bloc with distal spleno-pancreatectomy and parcelar gastrectomy.

Reconstruction of Inferior Right Hepatic Veins in Living Donor Liver Transplantation

BACKGROUND

A proper knowledge of the anatomy of the liver (including its vascular particularities) is mandatory in cases which are going to be submitted to major hepatic resection, including living donor liver transplantation.

CASE REPORT

We present the case of a living donor liver transplantation in which a particularity of the anatomy of the hepatic veins was reported for the donor: two inferior hepatic veins for segments 5 and 6. This particularity imposed the need for creation of a supplemental anastomosis in the recipient: a phleboplasty of the two inferior veins followed by direct re-implantation into the inferior cava vein. However, the postoperative course was uneventful for both the donor and the recipient.

CONCLUSION

In certain cases presenting vascular particularities such as two inferior hepatic veins, phleboplasty followed by reimplantation into the inferior cava vein might be needed in order to provide a good vascular outflow of the liver graft.

Association Between Secondary Peritoneal Hydatidosis and Peritoneal Carcinomatosis from Ovarian Cancer - A Case Report

Peritoneal carcinomatosis from ovarian cancer is unfortunately a very common finding, especially in patients diagnosed in very late stages of the disease. Nonetheless, it is not the only pathological condition inducing a diffuse involvement of the peritoneum; other entities can have an infectious or miscellaneous origin. However, the association of peritoneal carcinomatosis and parasitic infection has never been reported so far. We present the case of a 50-year-old patient who had been submitted to surgery for a hepatic hydatid cyst. Four years later, the patient was diagnosed with disseminated peritoneal lesions, which proved to have both parasite and neoplastic origin. The patient was re-submitted to surgery, and debulking resection of all pathological lesions was achieved. Although it is very rare, the association of peritoneal carcinomatosis and peritoneal hydatidosis should be taken into consideration whenever the patient reports a suggestive medical history for those two pathological findings.