The translational potential of circulating tumour DNA in oncology

The recent understanding of tumour heterogeneity and cancer evolution in response to therapy has raised questions about the value of historical or single site biopsies for guiding treatment decisions. The ability of ctDNA analysis to reveal de novo mutations (i.e., without prior knowledge), allows monitoring of clonal heterogeneity without the need for multiple tumour biopsies. Additionally, ctDNA monitoring of such heterogeneity and novel mutation detection will allow clinicians to detect resistant mechanisms early and tailor treatment therapies accordingly. If ctDNA can be used to detect low volume cancerous states, it will have important applications in treatment stratification post-surgery/radical radiotherapy and may have a role in patient screening. Mutant cfDNA can also be detected in other bodily fluids that are easily accessible and may aid detection of rare mutant alleles in certain cancer types. This article outlines recent advances in these areas.

Protective effect of sitagliptin and rosuvastatin combination on vascular endothelial dysfunction in type-2 diabetes

The present investigation aimed to evaluate the protective effects of sitagliptin, glimepiride, rosuvastatin and their combinations on oxidative stress and endothelial dysfunction in the aortic tissues in fructose-fed type-2 diabetic rats. Sitagliptin (20 mg/kg, p.o.), glimepiride (2 mg/kg, p.o.), rosuvastatin (5 mg/kg, p.o.) and their combinations were administered for 6 w after induction of diabetes by fructose (66%, w/v solution, p.o. for 8 w) in wistar rats. The effects were examined on body weight, serum glucose, triglyceride, cholesterol, blood pressure, heart rate, nitric oxide and antioxidant defensive enzymes. After completion of treatment schedule, the blood pressure was determined by invasive method and vascular reactivity was tested with adrenaline, noradrenaline and phenylephrine. Endothelial dysfunction was determined by acetylcholine and sodium nitroprusside-induced vasorelaxation studies on isolated rat aortas. Long term treatments significantly decreased body weight gain, serum glucose, triglyceride and cholesterol levels; normalize the heart rate, and blood pressure in fructose fed rats. The treatments significantly improved vascular reactivity to catecholamines with reduction in elevated blood pressure in type-2 diabetic rats. The significant improvement in the relaxant response to acetylcholine and sodium nitroprusside was obtained on isolated aortas. All the treatments were effective in restoring defensive antioxidant enzymes. Sitagliptin and rosuvastatin were able to reverse endothelial dysfunction in type-2 diabetes, but better ameliorating potential was found when used in combination.

Proceed™ mesh for laparoscopic ventral hernia repair

A laparoscopic approach to ventral hernia repair using Proceed mesh was associated with low conversion rate and no major complications in this study of single surgeon's experience.

Background and Objectives:

Laparoscopic technique to repair ventral hernia offers advantages over conventional open surgery such as shorter recovery time, decreased pain, and lower recurrence rates. There are a myriad of meshes available for laparoscopic repair of ventral hernias. This study evaluated the outcomes of laparoscopic repair of ventral hernias with Proceed mesh (Ethicon, Somerville, NJ, USA) in a single academic institution.

Methods:

An institutional review board–approved retrospective review was performed for 100 consecutive patients with ventral hernia who underwent a laparoscopic approach at our institution from August 2006 to February 2009. All patients were operated on by a single surgeon using a standard technique with transabdominal suture fixation and tacks.

Results:

The study included 100 consecutive patients (57 female and 43 male patients). The mean age was 55 years (range, 16–78 years), and the mean body mass index was 33.3 kg/m² (range, 19.6–68.9 kg/m²). Of the repairs, 27% were performed for a recurrent hernia. The mean and median size of the defect were 128 cm² and 119.5 cm² (range, 4–500 cm²), respectively. To ensure appropriate mesh overlap, the mean size of mesh was 253 cm² (range, 36–700 cm²). There were 4 conversions. The mean operative time was 117 minutes (range, 35–286 minutes). The mean length of stay was 1.9 days. There were no major abdominal complications. With a mean follow-up period of 50 months (range, 38–68 months), we have not recorded any recurrences. No mesh-related complications have been documented.

Conclusions:

The laparoscopic approach to ventral hernia repairs using Proceed mesh is associated with a low conversion rate and no major complications. At 50 months of follow-up, the recurrence rate is 0%. There were no mesh-related complications.

Patient-centered outcomes following laparoscopic ventral hernia repair: a systematic review of the current literature

BACKGROUND

The purpose of this study was to systematically review patients who underwent laparoscopic ventral hernia repair (LVHR) and assess quality of life, pain, functionality, and patient satisfaction.

DATA SOURCES

MEDLINE, PubMed, and Cochrane database search identified 880 relevant articles. After the limits were applied, 14 articles were accepted for review. The analysis included health-related quality of life (HRQoL) measures including quality of life, pain, function, satisfaction, and mental and emotional well-being.

CONCLUSIONS

Fourteen studies were reviewed. Mean study size was 92.6 subjects (24 to 306) and mean defect size was 71.7 cm(2). LVHR improved the overall HRQoL in 6 of the 8 studies. Thirteen studies assessing pain demonstrated improved pain scores relative to preoperative levels and long-term follow up. LVHR was not associated with long-term pain. Functionality improved in 12 studies. Return to work ranged from 6 to 18 days postoperatively in 50% of studies and physical function scores improved in the remaining 50% of the studies. Patient satisfaction improved after LVHR in all studies assessing patient satisfaction. Fixation methods did not influence HRQoL. Laparoscopic repair was associated with improving mental and emotional well-being in 6 of the 7 studies.

From theory to evidence: long-term evaluation of the mechanism of action and flap integration of distal vascularized lymph node transfers

BACKGROUND

Nonanatomic (distal) placement of vascularized lymph node (VLN) transfers have shown efficacy in the treatment of extremity lymphedema, but the mechanism by which these flaps provide relief of lymphedema remains unclear. Intrinsic lymphovenous connections have been previously shown to exist in the transferred flap. But, the long-term interaction of the VLN flap and surrounding lymphedematous extremity has not been previously investigated.

PATIENTS AND METHODS

A retrospective review of a prospective maintained database of patients who underwent VLN transfer was evaluated. Patients who underwent distal VLN transfer and had more than 1-year follow-up were identified. Lymphodynamic evaluation was performed using 0.3 to 0.6 mL indocyanine green (ICG) injection at 5 cm proximal to the flap edge on identified patients. Migration direction of dye and latency period was evaluated.

RESULTS

In total, 20 patients were identified who met inclusion criteria. Average long-term follow-up was 27.3 months. The average circumference reduction of the affected extremity was 40.5%. ICG appearance within the VLN flap was found in all patients occurring on average in 178.3 seconds. In all cases, flow occurred in the distal direction (toward the flap) with proximal placement of dye. Latency period was found to inversely correlate with circumference reduction (p < 0.01).

CONCLUSIONS

Distal, nonanatomic placement of VLN flaps provide sustained limb circumference reduction in extremity lymphedema patients following a minimum of 1-year postoperatively. Flap integration with the recipient site reliably occurs as witnessed with consistent ICG drainage, and occurs in the gravity-dependent direction. Faster clearance of ICG will result in improved clinical limb circumference reduction.

Monitoring patient-centered outcomes through the progression of breast reconstruction: a multicentered prospective longitudinal evaluation

Studies have shown that having breast reconstruction has a positive influence on patient satisfaction and health-related quality of life (HRQoL) at the conclusion of treatment. However, no study has critically evaluated changes to these patient-reported outcomes during the process of undergoing breast reconstruction. This study was to prospectively evaluate changes to patient-centered metrics through the progression of breast reconstruction. An IRB-approved prospective, multi-institutional study was performed for all patients undergoing breast reconstruction between 2009 and 2011. The Breast-Q reconstruction questionnaire was used for evaluation of HRQoL and was administered at five intervals in the perioperative period. Longitudinal evaluation was performed to assess changes to HRQoL metrics during this perioperative interval. One hundred and ten patients were enrolled, and 100 patients (91.9 %) completed appropriate follow-up. Preoperative HRQoL scores were higher in patients electing to forgo reconstruction (P < 0.004), while postoperative HRQoL scores consistently deteriorated at multiple time points following mastectomy as compared to reconstructed patients. On subgroup analysis, results indicated lower initial HRQoL scores in delayed reconstruction (P < 0.05) as compared to immediate reconstruction. These scores did, however, merge at approximately 9 months postoperatively. Changes to HRQoL outcomes occur through progression of breast reconstruction. Within the first year of surgery, early decreases are mirrored by significant increases at later time points above baseline levels when evaluating most forms of reconstruction. Choosing against reconstruction will likely result in continued deterioration of HRQoL for patients undergoing cancer surgery, but steady improvements can be expected if delayed reconstruction is chosen.

Patient-centred decision making in breast reconstruction utilising the delayed-immediate algorithm

Delayed-immediate reconstruction is an increasingly valuable algorithm for patients anticipating post-mastectomy radiation therapy. Despite the cosmetic and long-term advantages of autologous tissue repair, a subset of patients choose implant-based reconstruction after their initial preference for autologous reconstruction. A critical evaluation of patients who initially planned to undergo delayed-immediate reconstruction but later chose to continue with implant-based reconstruction has not been previously reported. A retrospective analysis of the senior author's (M.Y.N.) patients who initially intended to undergo delayed-immediate autologous breast reconstruction following mastectomy and chose to abandon autologous reconstruction in favour of prosthetic reconstruction was completed from 2005 to 2011. Seven patients (10 breasts) met inclusion criteria. The mean patient age and body mass index were 50.2 years and 32.1 kg m(-2), respectively. Expansion required an average of 4.4 office visits to achieve adequate expansion volume, mean 483 ml (240-600 ml). The mean time from expander placement to definitive reconstruction was 14.6 months. Mean follow-up time was 20.4 months. Complications included infection (1/7), incisional dehiscence (1/7) and capsular contracture (2/7), and late revision surgery was performed in two patients. Successful reconstruction was achieved in 100% of patients (7/7) with a patient-reported satisfaction of 100%. Patient motivations for changing the reconstructive algorithm included a faster post-operative recovery in four patients (4/7) and potential donor-site morbidity in three patients (3/7). Depression or cancer-related fatigue symptoms were self-reported in 4/7. Avoiding donor-site morbidity and a simpler recovery are the main factors that influence patients to change their desire for autologous reconstruction to an implant-based reconstruction. Cancer-related fatigue and depression are prevalent in this population and may be implicated in a patient's desire to undergo less extensive reconstructive surgery. Allowing for the choice of definitive implant-based reconstruction in select patients is safe and is likely to result in high patient satisfaction with satisfactory aesthetic outcomes.

Reduction mammaplasty and mastopexy in previously irradiated breasts

BACKGROUND

Little data exist on the safety of elective breast surgery following breast conservation therapy.

OBJECTIVES

The authors evaluate their experience performing reduction mammaplasties and mastopexies in previously irradiated breasts.

METHODS

A retrospective chart review was conducted of all reduction mammaplasties and mastopexies in previously irradiated breasts performed by the 2 senior authors (MYN and SLS) from 1995 to 2012 (n = 18). Patient records were analyzed for demographics, perioperative and postoperative details, and complications.

RESULTS

During the study period, 12 reduction mammaplasties and 6 mastopexies were performed on breasts previously treated with breast conservation therapy. The average study participant age was 49.5 years, and average body mass index was 29. Average preoperative bra cup size was D/DD. One patient was a former smoker; 17 were nonsmokers. Eleven of the 18 patients had been previously treated with chemotherapy; average time between radiation therapy and surgery was 2.5 years. Average specimen weight in the 12 reduction mammaplasties was 623 g. Twenty-two percent (n = 4) of patients experienced a total of 5 minor complications; none required a return to the operating room. One patient (6%) experienced a major complication resulting in approximately 50% loss of breast tissue, which was reconstructed with a latissimus dorsi musculocutaneous flap. Seventeen patients (94%) had successful outcomes with preoperative goals achieved.

CONCLUSIONS

In the previously irradiated breast, reduction mammaplasty and mastopexy should be approached with extra caution, but the surgeries may still be safely and successfully performed.

LEVEL OF EVIDENCE

4.

Freestyle propeller flaps from the lower abdomen: a valuable reconstructive option for proximal thigh defects

The concepts of freestyle flap design allows for flap creation from virtually every place in the body. Descriptions of named flaps based on their arterial origin are commonly described in the literature, allowing for predictable flap design. However, in certain cases, isolating a flap based on a Doppler signal and retrograde perforator dissection will allow for appropriate flap creation and wound coverage. We describe a 52-year-old female with a chronic open wound that failed wound care and local soft tissue rearrangement. This led to detection of a strong perforator signal in the lower lateral abdomen prompting the use of a freestyle propeller flap. The patient recovered without complication. Twelve-month follow-up demonstrated trunk and lower extremity mobility without impairment. We describe a successful and novel use of a rare, unnamed perforator from the lower, lateral abdomen by employing the freestyle propeller flap for coverage of a proximal thigh wound.

Use of intraoperative indocyanin-green angiography to minimize wound healing complications in abdominal wall reconstruction

Complication rates following abdominal wall reconstruction (AWR) remain high. Early complications are related to skin necrosis and delayed healing, whereas late complications are related to recurrence. When concomitant body contouring procedures are performed, complication rates can be further increased. It is hypothesised that fluorescent angiography using indocyanin green (ICG) can identify poorly perfused tissues and thus reduce the incidence of delayed healing. A retrospective review was conducted of all patients who underwent AWR with concomitant panniculectomy from 2007-2012. Intraoperative ICG angiography with the SPY system (LifeCell Corp.) was used to determine the amount of resection for body contouring in patients who underwent reconstruction in a cohort of patients. SPY-Q was used to assess relative perfusion of analysed areas. Preoperative, postoperative, and operative details were analyzed. Seventeen patients met inclusion criteria, 12 patients were included in the non-ICG cohort, while five patients were included in the ICG cohorts. Wound-healing complications occurred in 5/12 (42%) patients in the non-ICG cohort vs 1/5 (20%) of the ICG cohorts. A description of the sole patient with complications in the ICG cohort is illustrated. Operative debridement and wound infection development occurred more frequently in the non-ICG cohort compared with the ICG cohort (17%, 17% vs 0%, 0%, respectively). Average time to wound healing was 41.1 days. Intraoperative ICG angiography can accurately detect perfusion abnormalities and can decrease wound healing related complications in complex hernia repair with concomitant panniculectomy. Assessing and ensuring skin viability can decrease the need for operative debridement.

Complications of acellular dermal matrices in abdominal wall reconstruction

BACKGROUND

Acellular dermal matrices have been increasingly used in abdominal wall reconstruction. Unique characteristics of these grafts have allowed surgeons to reconstruct increasingly complex abdominal wall defects. This has resulted in a myriad of complications related to the acellular dermal matrix with unique management strategies as compared with synthetic mesh.

METHODS

A review of the literature was performed to identify studies evaluating the use and efficacy of acellular dermal matrices in abdominal wall reconstruction. Complication profiles were identified and are compared. Differences between porcine and human derivatives were identified.

RESULTS

Hernia recurrence, infection, skin necrosis, and fluid collections were among the most common complications following abdominal wall reconstruction identified in the literature. Differences among various acellular dermal matrix products make certain types more suitable for abdominal wall reconstruction.

CONCLUSIONS

Complications are frequent in abdominal wall reconstruction. Many acellular dermal matrices have properties that allow for conservative management and maintenance of reconstruction when complications occur. With traditional synthetic mesh reconstruction, complications likely result in mesh explantation and prolonged morbidity. With acellular dermal matrix reconstruction, however, more conservative treatment strategies will allow for mesh salvage.

The use of porcine acellular dermal matrix in a bridge technique for complex abdominal wall reconstruction: an outcome analysis

BACKGROUND

Outcomes using the porcine acellular dermal matrix (PADM) in abdominal wall reconstruction (AWR) have been reported when used for midline reinforcement; however, there have been no reports focused on outcomes when used as a bridging mesh.

METHODS

A retrospective review was conducted of all patients who underwent AWR with a non-cross-linked PADM as a bridged repair without midline fascial approximation.

RESULTS

Nine patients were identified with an average follow-up of 546 days. The average preoperative hernia defect diameter was 22.4 cm. After PADM placement, the average defect diameter was 9.8 cm. Complications occurred in 55.6% of patients, with PADM exposure occurring in all of these patients. No PADM was explanted, and all patients eventually healed. Abdominal wall eventration and/or recurrence occurred in 8 of 9 (88.9%) patients.

CONCLUSIONS

When fascial approximation cannot be achieved, PADM bridging may be the best option to avoid complications associated with synthetic mesh. However, there is a high potential for abdominal wall eventration and/or recurrence.

Gemcitabine in brief versus prolonged low-dose infusion, both combined with carboplatin for advanced non-small cell lung cancer

PURPOSE

Gemcitabine in low-dose prolonged infusion is a treatment with documented activity against a variety of tumors. The present study was conducted to evaluate the efficacy and safety of the combination of gemcitabine at a low-dose prolonged infusion in comparison with standard dose gemcitabine with carboplatin in chemonaive patients with advanced non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Sixty chemonaive patients with stage IIIB or IV NSCLC were included. Patients were randomly assigned 1:1 to receive 350 mg/m 2 gemcitabine in a 6-h infusion on days 1 and 8 and carboplatin area under the serum concentration time curve (AUC) 5 on day 1 versus gemcitabine 1,000 mg/m 2 on days 1 and 8 and carboplatin AUC 5 on day 1 (3-week cycle both). A total of 118 chemotherapy cycles, with a median of 4 cycles per patient (range 2-6), and 134 chemotherapy cycles, with a median of 4.47 cycles per patient (range 3-6) were administered in standard and low infusional dose arm, respectively.

RESULTS

Among patients in the standard arm, 40% had overall response rate (ORR), 33.3% had stable disease and 26.6% had progressive disease, while in low-dose infusional arm, 36.6% had ORR, 36.3% had stable disease and 26.6% had progressive disease (P = 0.992). Median progression-free survival was 5.5 months and 5.4 months, median overall survival was 9.7 months and 10.7 months, and 1-year survival was 33.7% and 36.6% in standard arm and low-dose infusion arm, respectively. Grade 3/4 toxicity was rare.

CONCLUSION

In NSCLC, gemcitabine low-dose prolonged infusion with carboplatin has low toxicity, especially thrombocytopenia, and has an activity comparable with gemcitabine given in higher dose in standard infusion.

Development of the ITER magnetic diagnostic set and specification

ITER magnetic diagnostics are now in their detailed design and R&D phase. They have passed their conceptual design reviews and a working diagnostic specification has been prepared aimed at the ITER project requirements. This paper highlights specific design progress, in particular, for the in-vessel coils, steady state sensors, saddle loops and divertor sensors. Key changes in the measurement specifications, and a working concept of software and electronics are also outlined.

Concept development for the ITER equatorial port visible∕infrared wide angle viewing system

The ITER equatorial port visible∕infrared wide angle viewing system concept is developed from the measurement requirements. The proposed solution situates 4 viewing systems in the equatorial ports 3, 9, 12, and 17 with 4 views each (looking at the upper target, the inner divertor, and tangentially left and right). This gives sufficient coverage. The spatial resolution of the divertor system is 2 times higher than the other views. For compensation of vacuum-vessel movements, an optical hinge concept is proposed. Compactness and low neutron streaming is achieved by orienting port plug doglegs horizontally. Calibration methods, risks, and R&D topics are outlined.

Survey on ventral hernias: surgeon indications, contraindications, and management of large ventral hernias

Repair of ventral hernias constitutes one of the most common surgical procedures. Although an abundance of data exists on objective outcome measures, very little information exists on subjective measures of surgeon preference and patient satisfaction in surgical management of ventral hernias. Moreover, there are minimal data on indications for elective repair of ventral hernias. Two questionnaires were sent to a population of general and plastic surgeons active in hernia surgery. The first of these aimed at gathering information from surgeons about their indications and contraindications for repair of ventral hernias. The second survey was aimed at determining surgeons' perception of patient satisfaction with repair of large ventral hernias (greater than 15 cm width). Five hundred sixty-eight surgeons responded to the first survey and 336 responded to the second survey. The most common indications for elective repair of abdominal wall hernias were generalized pain (68.7%) and cosmesis (54.6%), whereas the most common contraindications were morbid obesity (43.3%), American Society of Anesthesiologists Class III or IV (35.4%), and enterocutaneous fistula (33.1%). The majority of surgeons do not routinely repair large abdominal wall hernias in asymptomatic patients, but 31.6 per cent do repair asymptomatic large hernias. Most surgeons reported that the majority of patients had resolution of pain and subjective impression of improved cosmesis after surgery. This study demonstrates uniform indications and contraindications for surgical repair of ventral hernias among surgeons as well as surgeons' perception of improvements in satisfaction of most patients after surgery. Future studies will focus on comparing surgeon and patient satisfaction.

Survey on Ventral Hernias: Surgeon Indications, Contraindications, and Management of Large Ventral Hernias

Repair of ventral hernias constitutes one of the most common surgical procedures. Although an abundance of data exists on objective outcome measures, very little information exists on subjective measures of surgeon preference and patient satisfaction in surgical management of ventral hernias. Moreover, there are minimal data on indications for elective repair of ventral hernias. Two questionnaires were sent to a population of general and plastic surgeons active in hernia surgery. The first of these aimed at gathering information from surgeons about their indications and contraindications for repair of ventral hernias. The second survey was aimed at determining surgeons’ perception of patient satisfaction with repair of large ventral hernias (greater than 15 cm width). Five hundred sixty-eight surgeons responded to the first survey and 336 responded to the second survey. The most common indications for elective repair of abdominal wall hernias were generalized pain (68.7%) and cosmesis (54.6%), whereas the most common contraindications were morbid obesity (43.3%), American Society of Anesthesiologists Class III or IV (35.4%), and enterocutaneous fistula (33.1%). The majority of surgeons do not routinely repair large abdominal wall hernias in asymptomatic patients, but 31.6 per cent do repair asymptomatic large hernias. Most surgeons reported that the majority of patients had resolution of pain and subjective impression of improved cosmesis after surgery. This study demonstrates uniform indications and contraindications for surgical repair of ventral hernias among surgeons as well as surgeons’ perception of improvements in satisfaction of most patients after surgery. Future studies will focus on comparing surgeon and patient satisfaction.

Maximizing the use of the handheld Doppler in autologous breast reconstruction

The handheld acoustic Doppler is commonly used in the setting of autologous reconstruction. Like the color duplex Doppler, it can be used preoperatively but has the advantage of being used intraoperatively and postoperatively. It can be used as a sole modality or it can be used in conjunction with or to confirm the findings of CTA or MRA. This article focuses on the preoperative, intraoperative, and postoperative use of the handheld Doppler for free tissue transfer with an emphasis on perforator flap breast reconstruction.