Direct to Implant Reconstruction in Nipple Sparing Mastectomy: Patient Selection by Preoperative Digital Mammogram

Background:

Digital mammography clearly distinguishes gland tissue density from the overlying nonglandular breast tissue coverage, which corresponds to the existing tissue between the skin and the superficial layer of the fascia superficialis surrounding the gland (i.e., dermis and subcutaneous fat). Preoperative digital imaging can determine the thickness of this breast tissue coverage, thus facilitating planning and reducing the rate of necrotic complications after direct to implant (DTI) reconstruction in nipple sparing mastectomy (NSM).

Methods:

Thirty NSMs in 22 patients with type 3 tissue coverage (subcutaneous tissue thickness of 2 cm or more) were selected for DTI reconstruction after NSM to evaluate immediate skin flap/nipple areola complex ischemic complications and patient satisfaction.

Results:

We experienced no wound healing problems or ischemic complications immediately after surgery in our population. Only 1 seroma was observed as a short-term complication. Quality of life and patients’ satisfaction level were optimal at 3 and 6 months follow-up, respectively. The aesthetic results have been evaluated as good/excellent in all cases.

Conclusions:

DTI immediate reconstruction with silicone implants following NSM appears to be a safe option in selected cases with enough tissue coverage, also providing a high level of patient satisfaction. The possibility of selecting cases for this procedure according to the preoperative digital mammogram showing more than 2 cm of superficial tissues thickness may help reducing the risk of immediate ischemic complications.

Obesity and Prognostic Variables in Colombian Breast Cancer Patients: A Cross-Sectional Study

Introduction

Obesity is an established risk factor for cancer and cancer-related deaths, including that of the breast. While the prevalence of female obesity has accelerated over the past decade in many developing countries, such as Colombia, the prevalence of overweight and obesity specifically in breast cancer populations has not been fully described.

Methods

A cross-sectional study including 849 women diagnosed with breast cancer between 2009 and 2014. Based on body mass index, prevalence of overweight (BMI ≥ 25 < 30) and obesity (BMI ≥ 30) and associations of BMI with clinical and tumor histopathological features were analyzed.

Results

Colombian breast cancer patients had a prevalence of overweight of 34.28% and obesity of 28.15%. Mean BMI was comparable between premenopausal and postmenopausal women (27.2 versus 27.7, resp.). Among premenopausal women, higher BMI was significantly positively associated with hormone receptor negative tumors, as well as with greater lymphovascular invasion.

Conclusions

Colombian breast cancer patients exhibit a significant prevalence of overweight and obesity. Associations of high BMI and poor prognosis variables in the premenopausal population suggest risk of aggressive disease in this population. Future studies to further validate our observations are warranted in order to implement multidisciplinary clinical guidelines.

Optimizing Outcomes of Postmastectomy Breast Reconstruction With Acellular Dermal Matrix: A Review of Recent Clinical Data

Background: This article reports on the current use of acellular dermal matrix in breast reconstruction. Methods: A literature review of articles on acellular dermal matrix in breast reconstruction from January 1, 2010, through December 20, 2016, was performed and analyzed for trends in acellular dermal matrix use and differences between commonly used acellular dermal matrixes. Findings: Clinical findings varied but include improved cosmesis and more 1-stage reconstructions using acellular dermal matrix. Superiority of sterile versus aseptic acellular dermal matrixes was noted, and the increased incidence of red breast syndrome with AlloDerm was significant. The cost-effectiveness of acellular dermal matrix use despite increased upfront costs was also highlighted. Finally, the article emphasizes the importance of well-vascularized mastectomy flaps and the use of indocyanine green angiography as an adjunct in immediate reconstruction with acellular dermal matrix.

Specifying the molecular pattern of sporadic parathyroid tumorigenesis-The Y282D variant of the GCM2 gene

OBJECTIVE

Sporadic carcinoma of the parathyroid glands is a rare malignant neoplasia. The GCM2 gene encodes a transcription factor that is crucial to embryonic parathyroid development. The Y282D variant of GCM2 exhibits increased transcriptional activity, and the presence of this variant is significantly associated with a higher prevalence of primitive hyperparathyroidism. The present study investigated the prevalence of the Y282D variant of the GCM2 gene and its association with clinical parameters in patients with a definitive histological diagnosis of sporadic parathyroid carcinoma (SPC) or atypical adenoma (AA).

miRNA-21 enhances chemoresistance to cisplatin in epithelial ovarian cancer by negatively regulating PTEN

MicroRNAs (miRNAs) are small non-coding RNAs, 8-23 nucleotides in length, which regulate gene expression at the post-transcriptional level. The present study was performed to analyze the association between microRNA-21 and cisplatin resistance in epithelial ovarian cancer (EOC) SKOV3 and SKOV3/DDP cells. In this experiment, the resistance of SKOV3 and SKOV3/DDP cells to cisplatin was evaluated using the MTT assay. Reverse transcription-quantitative polymerase chain reaction analysis was used to assess miRNA-21 levels and phosphatase and tensin homolog (PTEN) mRNA levels. Western blotting was used to assess PTEN protein levels. miRNA-21 mimics or inhibitors were transfected into SKOV3 and SKOV3/DDP cells. Prior to transfection, higher expression levels of miRNA-21 were observed in SKOV3/DDP cells compared with SKOV3 cells. Following transfection with miRNA-21 mimics, SKOV3 cells demonstrated increased sensitivity to cisplatin compared with negative control cells. Following transfection with the miRNA-21 inhibitor, SKOV3/DDP cells demonstrated decreased sensitivity to cisplatin compared with negative control cells. Furthermore, PTEN mRNA expression levels in SKOV3 cells transfected with miRNA-21 mimics was significantly lower compared with negative control cells. These results suggested that miRNA-21 may regulate cisplatin resistance by negatively targeting PTEN in EOC.

Evolution of laparoscopic surgery in a high volume hepatobiliary unit: 150 consecutive pure laparoscopic hepatectomies

INTRODUCTION

Compared to other surgical areas, laparoscopic liver resection (LLR) has not been widely implemented and currently less than 20% of hepatectomies are performed laparoscopically worldwide. The aim of our study was to evaluate the feasibility, and the ratio of implementation of LLR in our department.

METHODS

We analyzed a prospectively maintained database of 749 liver resections performed during the last 10-year period in a single centre.

RESULTS

A total of 150 (20%) consecutive pure LLR were performed between 2005 and 2015. In 87% of patients the indication was the presence ofprimary or metastatic liver malignancy. We performed 30 major hepatectomies (20%) and (80%) were minor resections, performed in all liver segments. Twelve patients were operated twice and 2 patients underwent a third LLR. The proportion of LLR increased from 12% in 2011 to 62% in the last year. Conversion rate was 9%. Overall morbidity rate was 36% but only one third were classified as severe. The 90-day mortality rate was 1%. Median hospital stay was 4 days and the rate of readmissions was 6%.

CONCLUSIONS

The implementation of LLR has been fast with morbidity and mortality comparable to other published series. In the last 2 years more than half of the hepatectomies are performed laparoscopically in our centre.

The current state of intermittent intraoperative neural monitoring for prevention of recurrent laryngeal nerve injury during thyroidectomy: a PRISMA-compliant systematic review of overlapping meta-analyses

PURPOSE

Recurrent laryngeal nerve (RLN) injury is one of the most common and detrimental complications following thyroidectomy. Intermittent intraoperative nerve monitoring (I-IONM) has been proposed to reduce prevalence of RLN injury following thyroidectomy and has gained increasing acceptance in recent years.

METHODS

A comprehensive database search was performed, and data from eligible meta-analyses meeting the inclusion criteria were extracted. Transient, permanent, and overall RLN injuries were the primary outcome measures. Quality assessment via AMSTAR, heterogeneity appraisal, and selection of best evidence was performed via a Jadad algorithm.

RESULTS

Eight meta-analyses met the inclusion criteria. Meta-analyses included between 6 and 23 original studies each. Via utilization of the Jadad algorithm, the selection of best evidence resulted in choosing of Pisanu et al. (Surg Res 188:152-161, 2014). Five out of eight meta-analyses demonstrated non-significant (p > 0.05) RLN injury reduction with the use of I-IONM versus nerve visualization alone.

CONCLUSIONS

To date, I-IONM has not achieved a significant level of RLN injury reduction as shown by the meta-analysis conducted by Pisanu et al. (Surg Res 188:152-161, 2014). However, most recent developments of IONM technology including continuous vagal IONM and concept of staged thyroidectomy in case of loss of signal on the first side in order to prevent bilateral RLN injury may provide additional benefits which were out of the scope of this study and need to be assessed in further prospective multicenter trials.

Transoral endoscopic thyroidectomy: preliminary experience in Italy

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a feasible novel surgical procedure that does not need visible incisions. We describe our initial experience with TOETVA. We recruited 15 patients who were willing to undergo TOETVA. Inclusion criteria were (a) patients who had a neck ultrasound (US) with a estimated thyroid diameter not larger than 10 cm; (b) US estimated gland volume ≤45 mL; (c) nodule size ≤50 mm; (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (e) follicular neoplasm; (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through a three-port technique placed at the oral vestibule, one 10-mm port for 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO₂ insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments and intraoperative neuromonitoring. There were 34% total thyroidectomies and 66% hemithyroidectomies. All TOETVA procedures were performed successfully with no conversions. The mean operative time was 87.6 (59-118) min for lobectomy and 107.6 (99-135) min for bilateral procedure. We observed one case of transient postoperative hypocalcemia. There was no recurrent laryngeal nerve palsy. The cosmetic result was excellent in all patients. This is the first case series of TOETVA in Italy. TOETVA may provide a method for ideal cosmetic results. The results are encouraging, and we are optimistic about the future expansion of its applicability.

Transoral thyroidectomy: why is it needed?

Transoral thyroidectomy (TOT) represents reasonably the desirable minimally invasive approach to the gland due to the scarless non-visible incisions, the limited distance between the gland and the access that minimize tissue dissection and respect of the surgical anatomical planes. Patients are routinely selected according to an extensive inclusion criteria: (I) ultrasonographically (US) estimated thyroid diameter not larger than 10 cm; (II) US gland volume ≤45 mL; (III) nodule size ≤50 mm; (IV) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (V) follicular neoplasm; (VI) papillary microcarcinoma without lymph node metastasis. The operation is realized through median, central approach which allows bilateral exploration of the thyroid gland and central compartment. TOT is succeed both endoscopically adopting ordinary endoscopic equipments or robotically. In detail three ports are placed at the inferior oral vestibule: one 10-mm port for 30° endoscope and two 5-mm ports for dissecting, coagulating and neuromonitoring instruments. Low CO₂ insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sterncleidomuscles similar to that of conventional thyroidectomy. TOT is now reproducible in selective high volume endocrine centers.

Active Surveillance for Patients With Papillary Thyroid Microcarcinoma: A Single Center's Experience in Korea

CONTEXT

Papillary thyroid microcarcinoma (PTMC) usually has an excellent prognosis.

OBJECTIVE

To evaluate the three-dimensional structures of PTMCs, using serial neck ultrasonography (US) in patients under active surveillance.

DESIGN AND SETTING

A retrospective cohort study.

PARTICIPANTS

In total, 192 patients diagnosed with PTMC under active surveillance for >1 year were included in a median 30-month follow-up. Changes in tumor size were evaluated not only using the maximal tumor diameter but also the tumor volume.

RESULTS

The median age of patients was 51.3 years and 145 patients (76%) were female. The median initial maximal tumor diameter and tumor volume were 5.5 mm and 48.8 mm3, respectively. The tumor size increased in 27 patients (14%); 23 patients showed a tumor volume increase >50% without a maximal diameter increase of ≥3 mm. The other four patients had both an increasing tumor volume and increasing maximal tumor diameter ≥3 mm. One patient (0.5%) had newly appeared cervical lymph node (LN) metastasis at 3 years after the initial diagnosis. There were no significant risk factors associated with increased tumor size, such as age, sex, or Hashimoto thyroiditis. Twenty-four patients (13%) underwent delayed thyroid surgery at a median of 31.2 months and seven (29%) had cervical LN metastasis on pathologic examination.

CONCLUSION

Some PTMCs could grow significantly after a relatively short period of active surveillance. We also found that the change in tumor volume was more sensitive to detect tumor progression than the change in the maximal tumor diameter.

Overview of robotic thyroidectomy

With the advancement and adaptation of technology, there has been a tremendous evolution in the surgical approaches for thyroidectomy. Robotic thyroidectomy has become increasingly popular worldwide attracting both surgeons and patients searching for new and innovative techniques for thyroidectomy with a superior cosmetic result when compared to the conventional open procedures. In this review, we describe the following surgical approaches for robotic thyroidectomy: transaxillary, retroauricular (facelift) and transoral. The advantages and disadvantages as well as limitations of each approach are examined, and future directions of robotic thyroidectomy are discussed.

Transoral endoscopic thyroidectomy using vestibular approach: updates and evidences

Recently, natural orifice transluminal endoscopic surgery (NOTES) has been applied in thyroid surgery with transoral access. The benefit of transoral endoscopic thyroidectomy is the potential for scar-free surgery. However, there are many concerns over some aspects, such as infection, recurrent laryngeal nerve injury, and oncological outcome. In this paper, we have reviewed the development history and the current clinical evidence of this innovative surgery. We conclude that the transoral endoscopic thyroidectomy vestibular approach (TOETVA) is feasible and can be considered no longer an experimental operation.

The psychosocial impact of contralateral risk reducing mastectomy (CRRM) on women: A rapid review

OBJECTIVES

For women who have been diagnosed with unilateral breast cancer, there is an increasing trend for them to request removal of the contralateral healthy breast, the so-called contralateral risk reducing mastectomy (CRRM). The current literature is only just beginning to identify patient-reported reasons for undergoing CRRM and associated patient-reported outcomes. It is also unclear whether women at moderate/high risk of developing a subsequent primary contralateral breast cancer report similar outcomes to those considered to be at low/average risk. This lack of knowledge provides the rationale for this review.

METHODS

A rapid review methodology was undertaken to identify and explore the published research literature focused on the longer term (>5 y) psychosocial impacts on women who undergo CRRM.

RESULTS

Fifteen studies were identified. No UK studies were identified. High satisfaction and psychosocial well-being were consistently reported across all studies. Reducing the risk of a subsequent contralateral breast cancer and therefore reducing cancer-related anxiety, and satisfaction with cosmesis, were key themes running across all studies explaining satisfaction. Dissatisfaction was associated with adverse effects such as poor cosmesis, body image changes, femininity, sexual relationships, reoperations for acute and longer term complications, and reconstructive problems.

CONCLUSIONS

Satisfaction and psychological well-being following CRRM was consistently high across all studies. However, the findings suggest women need to be more fully informed of the risks and benefits of CRRM and/or immediate/delayed reconstruction to support informed decision making.

Development of video-assisted breast cancer surgery: Initial experience with a novel method for creating working space without prior liposuction

Endoscopic techniques are promising in breast surgery. In order to create working space, liposuction is widely used in video-assisted breast surgery (VABS). However, the use of liposuction is likely associated with side effects that may partly limit the application of VABS. Therefore, a new technique of endoscopic axillary lymphadenectomy without prior liposuction was developed by our group. A total of 106 female patients underwent VABS, with special adaptation of the video-assisted surgical procedures previously described. Differing from other endoscopic surgery techniques, our adaptations of VABS included the selection of the working instruments, trocar placement, creation of working space, order of axillary lymph node dissection and method of mastectomy. The operative time was 50–180 min (mean, 85.5 min). The intraoperative blood loss ranged from 20 to 100 ml (mean, 48 ml). The mean lymph node number harvested was 11.5 (range, 6–31). No serious intra- or postoperative complications were recorded. There was no axillary tumor relapse, trocar site tumor implantation or upper limb edema. Without prior liposuction, our new technique of VABS reduced the blood loss volume, endoscopic surgery time, total volume of drainage fluid and, most importantly, the risk of port-site metastases. This new technique appears to have great clinical potential and good prospects for future endoscopic breast surgery development.

Cutaneous angiosarcoma: report of three different and typical cases admitted in a unique dermatology clinic

Angiosarcoma is a rare and aggressive tumor with high rates of metastasis and relapse. It shows a particular predilection for the skin and superficial soft tissues. We report three distinct and typical cases of angiosarcoma that were diagnosed in a single dermatology clinic over the course of less than a year: i) Angiosarcoma in lower limb affected by chronic lymphedema, featuring Stewart-Treves syndrome; ii) a case of the most common type of angiosarcoma loated in the scalp and face of elderly man and; iii) a skin Angiosarcoma in previously irradiated breast. All lesions presented characteristic histopathological findings: irregular vascular proliferation that dissects the collagen bundles with atypical endothelial nuclei projection toward the lumen.

Ultrasound guided percutaneous microwave ablation of benign breast lesions

The benign breast lesions (BBLs) share a high incidence for women and therapy methods with minimal invasion and better cosmetic outcome are thirsted for. In this study, 122 patients with 198 biopsy-proved BBLs were enrolled. Ultrasound (US)-guided microwave ablation (MWA) was performed with local anesthesia from November, 2013 to April, 2016. The mean longest tumor size assessed was 1.6±0.7 cm (ranging 0.7-4.9 cm). MWA was successfully performed in all cases including 85 lesions adjacent to the skin, pectoralis and areola. The mean ablation time was 3.2mins (ranging 0.5-18.3 mins). 99.5% of BBLs showed complete ablation when assessed by magnetic resonance imaging and 100% of them by US. At the median 14-month follow-up, the BBLs were not palpable in 45.9 % of the cases (palpable in 90.2 % of the cases before MWA) and the mean volume reduction ratio was 78.4±33.5% for total lesions and 89.3±20.8%, 84.7±27.6% and 55.9±32.9% for ≤1.0 cm, 1.1-2.0cm and >2.0 cm lesions in 12-month follow-up, respectively. Cosmesis were reported as good or excellent in 100 % by physician and patients. No side effect was found. The MWA of the BBLs proved feasible and effective, while showing meaningful reduction in volume, palpability and cosmetic satisfying outcomes.

Impact of RASSF1A gene methylation on the metastatic axillary nodal status in breast cancer patients

Hypermethylation of CpG islands is a hallmark of cancer and occurs at an early stage in breast tumorigenesis. To gain insight into the epigenetic switches that may promote and/or contribute to the initial neoplastic events during breast carcinogenesis, the present study focused on the DNA methylation profile of invasive breast carcinoma. The aim of the study was to evaluate the prognostic significance of Ras association domain family 1 isoform A (RASSF1A) promoter methylation status in operable breast cancer, and to analyze the utility of this biomarker regarding its association with metastatic and nonmetastatic axillary nodal status. For this purpose, formalin-fixed, paraffin-embedded tissue specimens from 116 breast cancer patients with known axillary nodal status were subjected to assessment of RASSF1A promoter methylation status by methylation-specific polymerase chain reaction (MSP) and methylation-sensitive high-resolution melting assay, and the results were subsequently validated by bisulfite sequencing. A multinomial logistic regression model was used to model the dependence of distinct levels of methylation status of the RASSF1A promoter on the nodal status. Promoter region CpG hypermethylation was identified by MSP in 97 (83.6%) of 116 primary breast tumors, while hypermethylation of RASSF1A was confirmed by MS-HRM in 107 (92.2%) of 116 cases of breast cancer. Based on the results of the multinomial logistic regression model, there was no significant difference between the frequency of RASSF1A promoter methylation and axillary lymph node status of patients in general. However, upon adjustment of pN stage, an association was identified between pN0 lymph node-negative status (without axillary metastases) and percentage of RASSF1A methylation in two groups of heterogeneous methylated alleles with ≤50% methylated (P<0.05) and >50% methylated alleles (P<0.0001). If a patients' nodal status changes from pN- to pN+ then the risk of having >50% methylated alleles increases by 7%. The present study revealed a specific phenomenon, suggesting that the presence of heterogeneous methylated alleles in the RASSF1A gene is significantly associated with lymph node-negative status in breast cancer patients. Furthermore, greater significance with negative axillary nodal status was observed with a higher level of heterogeneous methylated alleles in the RASSF1A gene.

Ablation zone visualization enhancement by periodic contrast-enhancement computed tomography during microwave ablation

PURPOSE

Intra-procedural contrast-enhanced computed tomography (CECT) has been proposed to monitor the growth of thermal ablations. The primary challenge with multiple CT acquisitions is reducing radiation dose while maintaining sufficient image quality. The purpose of this study was to evaluate the feasibility of applying local highly constrained backprojection reconstruction (HYPR-LR) on periodic CECT images acquired with low-dose protocols, and to determine whether the ablations visible on CT were commensurate to gross pathology.

METHODS

Low-dose (CTDIvol≤1.49mGy), temporal CECT volumes were acquired during microwave ablation on normal porcine liver. HYPR processing was performed on each volume after image registration. Ablation signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were collected to evaluate the degree of enhancement of image quality and ablation zone visualization. Ablation zones were manually segmented on HYPR and non-HYPR images and compared spatially using Dice's coefficient. The dimensions of ablation zones were also compared to gross pathology by correlation and dimensional differences.

RESULTS

The SNR and CNR of ablation zones were increased after HYPR processing. The manually segmented ablation zone was highly similar to gross pathology with a Dice coefficient of 0.81 ± 0.03, while the low-dose CECT had a smaller Dice coefficient of 0.72 ± 0.05. Both HYPR and low-dose CECT had high correlation to gross pathology (0.99 and 0.94, respectively), but the variance of measurements were lower after HYPR processing compared to unprocessed images. The relative difference in area, length of long axis, and length of short axis for HYPR image were 13.1 ± 5.6%, 9.7 ± 4.2%, and 15.2 ± 2.8%, which were lower than those for low-dose CECT at 37.5 ± 6.0%, 17.7 ± 2.8%, and 28.9 ± 5.4%.

CONCLUSION

HYPR processing applied to periodic CECT images can enhance ablation zone visualization. HYPR processing may potentially enable CECT in real-time ablation monitoring under strict regulation of radiation dose.

RNA-binding protein HuR promotes bladder cancer progression by competitively binding to the long noncoding HOTAIR with miR-1

The elevated expressions of RNA-binding protein HuR and long noncoding HOX transcript antisense RNA (HOTAIR) are observed in numerous cancers. And HuR often exerts its promotive effects on tumorigenesis via binding to AU-rich elements in target transcripts and thus regulating the expression of target transcripts. However, the roles and related mechanisms of HuR/HOTAIR in bladder cancer progression have never been formally tested. Here, we found that the expression level of HuR was higher in clinical bladder cancer samples than in normal adjacent samples, mirroring that of HOTAIR, and their expression showed strong correlation. Knockdown of HuR/HOTAIR in bladder cancer inhibited cell proliferation, migration, invasion, and promoted cell apoptosis. Notably, HuR interacted and stabilized HOTAIR mRNA and knockdown of HuR decreased HOTAIR expression. Additionally, HOTAIR was identified as a potential target of miR-1 in bladder cancer cells. Interestingly, overexpression of HOTAIR enhanced HuR expression and increased cytoplasmic accumulation of HuR, thus enhancing HOTAIR expression in turn. But mutation of miR-1 binding site in HOTAIR canceled the effects of HOTAIR on HuR expression. Overall, we identified a regulatory loop between HOTAIR and HuR during the progression of bladder cancer, which could be exploited to curb bladder cancer progression.

[Alternative approaches in thyroid surgery]

In thyroid surgery multiple different cervical minimally invasive (partly endoscopically assisted) and extracervical endoscopic (partly robot-assisted) approaches have been developed in the last 20 years. The aim of all these alternative approaches to the thyroid gland is optimization of the cosmetic result. The indications for the use of alternative and conventional approaches are principally the same. Important requirements for the use of alternative methods are nevertheless a broad experience in conventional thyroid operations of the thyroid and adequate patient selection under consideration of the size of the thyroid and the underlying pathology. Contraindications for the use of alternative approaches are a large size of the thyroid gland including local symptoms, advanced carcinomas, reoperations and previous radiations of the anterior neck. The current article gives an overview of the clinically implemented alternative approaches for thyroid surgery. Of those the majority must still be considered as experimental. The alternative approaches to the thyroid gland can be divided in cervical minimally invasive, extracervical endosopic (robot-assisted) and transoral operations (natural orifice transluminal endoscopic surgery, NOTES). Since conventional thyroid operations are standardized procedures with low complication rates, alternative approaches to the thyroid gland are considered critically in Germany. The request for a perfect cosmetic result should not overweigh patients' safety. Only a few alternative approaches (e. g. MIVAT, RAT) can yet be considered as a safe addition in experienced hands in highly selected patients.

Small refinements in breast reconstruction: a technique for inframammary fold creation

BACKGROUND

In breast reconstructive surgery, the inframammary fold (IMF) is an essential component of breast identity. The lack of the IMF following previous mastectomy requires restoration. We have developed a new IMF reconstruction technique using the posterior sheet (PS) of the expander capsule. This article presents our 10-year experience of performing this original technique during two-stage breast reconstruction.

METHODS

Preoperatively, the midline, lateral, and medial borders (MBs) of the implant pocket and the new IMF line were marked. After extracting the expander, the anterior sheet of the expander capsule was removed with the exception of its lowest 2-cm portion. Two needles were placed at the intersection of the new IMF line with the lateral border (LB) of the implant pocket and its MB. Within the pocket, horizontal dissection of the PS of the capsule was performed from one needle to another, after which the sheet was mobilized downward. The mobilized free border of the PS was pulled upward until the inframammary crease was at the new marked location, and then fixed with non-absorbable interrupted sutures to the underlying tissues. An implant was placed over this layer. The covering tissues were then closed.

RESULTS

A total of 321 patients were included. The median age was 38 years (range, 18-58 years). No serious wound complications were observed. Breast-thoracic angle decreased in 21 patients (6.5%), and the distance from the IMF to the lower border of breast segment III was greater than that of the contralateral breast in 14 patients (4.4%).

CONCLUSION

This technique provides a well-defined IMF without indentations or retraction. The results are stable on long-term follow-up and provide a sharp breast-thoracic angle, which is crucial in creating natural-looking ptosis of the reconstructed breast.

Surveillance and Prevention of Surgical Site Infections in Breast Oncologic Surgery with Immediate Reconstruction

Surgical site infection (SSI) after immediate breast reconstruction is much more common than would be expected after a clean surgical procedure. Although the SSI rates reported in individual studies are quite variable, there are no obvious explanations for the variation in infection rates between institutions. The microbiology of these SSIs is unusual, with higher proportions of infections caused by atypical Myobacterium species and Gram-negative bacilli than would be expected for this anatomic site. In an effort to prevent SSIs, many surgeons use a variety of different practices including irrigation and soaking of implants with antibiotic solutions and prolonged duration of prophylactic antibiotics, although the literature to support these practices is very sparse. In particular, prolonged use of antibiotics post-discharge is concerning due to the potential for harm, including increased risk of Clostridium difficile infection, development of antibiotic resistant organisms, and drug-related allergic reactions. With higher rates of mastectomy and breast implant reconstruction in women with early-stage breast cancer, including greater utilization of reconstruction in higher-risk individuals, the number of women suffering from infection after oncologic reconstruction will likely continue to increase. It is imperative that more research be done to identify modifiable factors associated with increased risk of infection. It is also essential that larger studies with rigorous study designs be performed to identify optimal strategies to decrease the risk of SSI in this vulnerable population.

Continuous intraoperative neural monitoring in thyroid surgery: a Mexican experience

Intraoperative continuous neural monitoring (C-IONM) during thyroid surgery has been recognized as a useful tool to identify and confirm recurrent laryngeal nerve integrity. The aim of the present study is to analyze electromyographic features and thresholds for normal vocal fold function in our initial experience with C-IONM in thyroid surgery. C-IONM was utilized in 57 patients who underwent thyroid surgery between July 2012 and December 2015. EMG parameters were analyzed looking for potential predictors of postoperative vocal fold dismotility. There were 54 females (94.7%) and 3 males (5.3%) with a mean age of 46.7 ± 11.6 years. C-IONM was successfully registered in 89 of 107 nerves at risk (83.1%). Mean basal amplitude was 727.31 ± 471.25 μV and mean final amplitude was 650.27 ± 526.87 μV (P = 0.095, CI 95% 13.83-167.91). Mean basal latency was 5.23 ± 1.42 mS and mean final latency was 5.18 ± 1.50 mS (P = 0.594, CI 95% 0.39-0.24). Four patients had transient postoperative vocal fold paresis. None of these four patients had loss of signal (LOS), three had transient decrease in amplitude, and one had a normal registry throughout the operation. C-IONM is a useful tool to identify patients in whom intraoperative RLN is at risk during surgery. Final amplitude above 500 μV and no LOS is associated with RLN integrity and normal postoperative vocal fold function.

Thyrolipomatosis: A case report with review of the literature

Fatty tissue is not usually present within the thyroid gland. Only a few fat-containing thyroid lesions have been reported to date, and thyrolipoma is the most common fat-containing lesion of the thyroid gland. Thyrolipomatosis is a condition characterized by diffuse mature adipose cell infiltration of the normal thyroid gland. In this report, we describe what is, to the best of our knowledge, the 12th documented case of thyrolipomatosis, and review the fat-containing lesions of the thyroid gland. A 68-year-old Japanese woman presented with a neck mass that had first been noticed ~7 years earlier. A computed tomography scan revealed diffuse thyroid gland enlargement and total thyroidectomy was performed. The histopathological examination revealed that mature fatty tissue was diffusely distributed throughout the thyroid gland, as well as among the hyperplastic follicles. Capsular formation or amyloid deposition were not observed. Nuclear grooves or intranuclear cytoplasmic inclusions were not observed. Accordingly, thyrolipomatosis was diagnosed. Albeit rare, various neoplastic and non-neoplastic thyroid lesions may contain mature fatty tissue. Therefore, thyrolipomatosis must be included in the differential diagnostic consideration of fat-containing lesions of the thyroid gland.

Diagnostic value of endoscopic appearance during ductoscopy in patients with pathological nipple discharge

Background

To explore the features of ductoscopic appearance that may be diagnostic in patients with pathologic nipple discharge (PND) and to discuss the diagnostic criteria for intraductal tumors.

Methods

We reviewed 247 patients with PND but without a palpable mass who were evaluated using either surgical biopsy or excision. Data concerning patient age, duration of discharge, discharge color, and the details of endoscopic appearance were analyzed according to the pathological results.

Results

The postoperative diagnosis in 61 patients (24.70%) was a nonmass lesion, and 186 patients (76.52%) had an intraductal tumor. Among those with intraductal lesions, 10 patients (4.05%) had a malignant tumor, including 4 (1.62%) with ductal carcinoma in situ and 6 (2.43%) with invasive ductal carcinoma. On univariate analysis, patients of older age with spontaneous and bloody discharge were more likely to suffer from intraductal lesions. On logistic regression analysis, bloody nipple discharge, morphology, and a broad lesion base revealed by ductoscopy showed a statistically significant correlation with malignancy (p = 0.001, p < 0.001, p = 0.022, respectively).

Conclusions

Both clinical features and endoscopic appearance are significant for the precise diagnosis of an intraductal lesion seen on ductoscopy. The endoscopic features of bloody discharge, morphology, and a broad lesion base are independent risk factors for malignancy and represent new criteria for the diagnosis of patients with PND.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3288-3) contains supplementary material, which is available to authorized users.

Massive Benign Phyllodes Tumour of Breast Complicating Pregnancy

Phyllodes tumour of the breast, earlier called cystosarcomaphyllodes, is a rare fibroepithelial breast neoplasm that occurs in all age groups from adolescents to elderly. Phyllodes tumour occurring during pregnancy and associated with lactating breast is extremely rare. Giant phyllodes tumours or giant fibroadenomas are those measuring more than 10 cms in diameter and weighing more than 500 gm. Phyllodes tumour typically exhibits an exclusive intracanalicular growth pattern of fibroepithelial cells with classical, deep leaf-like stromal projections into dilated lumens from which its name "phyllodes" is derived. A 32-year-old primigravida at 38 weeks of gestation, presented with massive and heavy swelling of the left breast, growing over the last eight months. Physical examination revealed a massively enlarged left breast with palpable, firm, nodular mass measuring 10 x 20 cm and occupying whole of the left breast. A trucut biopsy demonstrated a fibroepithelial lesion suggestive of benign phyllodes tumour. Simple mastectomy was performed six days after the delivery of the baby by caesarean section. The histopathological report confirmed the diagnosis as benign phyllodes tumour with ductal hyperplasia and no atypia. We are reporting this case because of its massive size, associated with lactating breast and difficulty in histopathological differentiation from Giant fibroadenoma.

Patterns of Treatment Failure in Anaplastic Thyroid Carcinoma

BACKGROUND

Anaplastic thyroid cancer (ATC) is one of the most lethal forms of cancer with a high mortality rate. Current guidelines support surgery for resectable ATC followed by external beam radiation therapy (EBRT) with or without chemotherapy. Treatment for those who are unresectable is palliative. Our goal was to examine first-line therapies as well as the role of genomic profiling in an effort better understand how to approach ATC.

METHODS

This is a retrospective study of ATC patients who were seen at our institution from January 2013 to October 2015. Median overall survival (OS) and time to treatment failure (TTF) were calculated by the Kaplan-Meier method.

RESULTS

Fifty-four patients were included. Median age at diagnosis was 63 years and 29/54 (54%) were women. The majority had stage IVC disease at diagnosis (50%), followed by IVB (32%), and IVA (18%). Approximately 93% had somatic gene testing. Initial treatment was surgery in 23 patients, EBRT with or without radiosensitizing chemotherapy in 29 patients, and systemic chemotherapy in 2 patients. Nineteen patients had all three treatment modalities. For the entire cohort, median OS was 11.9 months with 39% survival at 1 year and median TTF was 3.8 months. The majority of patients (74%) developed new distant metastasis or progression of existing metastatic disease. Patients who received trimodal therapy consisting of surgery, EBRT, and chemotherapy had a median OS of 22.1 months versus 6.5 months in those who received dual therapy with EBRT and chemotherapy (p = 0.0008). The TTF was the same in the two groups (7.0 and 6.5 months, respectively). Men were three times more likely to die from ATC than women (p = 0.0024). No differences in OS or TTF were noted based on tumor size (5 cm cutoff), age (60 years cutoff), or presence of any mutation. There was a trend toward shorter TTF in patients with somatic mutations in TP53.

CONCLUSION

Patients with ATC amenable to aggressive tri-modal therapy demonstrate improved survival. The short TTF, due primarily to distant metastatic disease, highlights the potential opportunity for improved outcomes with earlier initiation of systemic therapy including adjuvant or neoadjuvant therapy.

Pancreatic Neuroendocrine Tumors (panNETs): Analysis of Overall Survival of Nonsurgical Management Versus Surgical Resection

BACKGROUND

Outcomes of patients with pancreatic neuroendocrine tumors (panNETs) undergoing surgical or nonsurgical management and outcomes of enucleation versus standard resection were compared.

METHODS

MEDLINE, EMBASE, PubMed, Scopus, and Cochrane were queried (2000 to present). All studies comparing patients undergoing surgical versus nonsurgical treatments, or enucleation versus standard resection, were included. Pooled risk ratios and 95% CI for survival were calculated.

RESULTS

Eleven studies met criteria with 1491 resected and 1607 nonsurgically managed patients. Meta-analysis showed improved overall survival with resection at 1 year (risk ratio (RR) = 1.281, CI 1.064-1.542, p = 0.009), 3 years (RR = 1.837, CI 1.594-2.117, p < 0.001), and 5 years (RR = 2.103, CI 1.50-2.945, p < 0.001). OS of patients with resected nonfunctioning panNETs was improved at 3 years (RR = 1.847, CI 1.477-2.309, p < 0.001) and 5 years (RR = 1.767, CI 1.068-2.924, p = 0.027). OS was improved when panNETs ≤2 cm were resected at 3 years (RR = 1.695, CI 1.269-2.264, p < 0.001) and 5 years (RR = 2.210, CI 1.749-2.791, p < 0.001). Fifteen articles met criteria for enucleation versus standard resection (n = 1035; 620 were nonfunctioning). Enucleation had shorter operative time (weighted mean difference (WMD) = -95.6 min, 95% CI -131.4 to -59.8, p < 0.01), less operative blood loss (WMD = -172.6 ml, 95% CI -340 to -5.1, p = 0.04), but increased postoperative pancreatic fistula (POPF) (RR = 2.08, 95% CI 1.39-3.12, p < 0.01).

CONCLUSION

Surgical resection of panNETs, including small and nonfunctioning, appears to be associated with improved OS. Enucleation is associated with shorter operative time, less blood loss, but greater incidence of POPF. Prospective, randomized clinical trials are needed to confirm these results.

Shaped versus Round Implants in Breast Reconstruction: A Multi-Institutional Comparison of Surgical and Patient-Reported Outcomes

BACKGROUND

Since the 2012 approval of shaped implants, their use in breast reconstruction has increased in the United States. However, large-scale comparisons of complications and patient-reported outcomes are lacking. The authors endeavored to compare surgical and patient-reported outcomes across implant types.

METHODS

The Mastectomy Reconstruction Outcomes Consortium database was queried for expander/implant reconstructions with at least 1-year postexchange follow-up (mean, 18.5 months). Outcomes of interest included postoperative complications, 1-year revisions, and patient-reported outcomes. Bivariate and mixed-effects regression analyses evaluated the effect of implant type on patient outcomes.

RESULTS

Overall, 822 patients (73.5 percent) received round and 297 patients (26.5 percent) received shaped implants. Patients undergoing unilateral reconstructions with round implants underwent more contralateral symmetry procedures, including augmentations (round, 18.7 percent; shaped, 6.8 percent; p = 0.003) and reductions (round, 32.2 percent; shaped, 20.5 percent; p = 0.019). Shaped implants were associated with higher rates of infection (shaped, 6.1 percent; round, 2.3 percent; p = 0.002), that remained significant after multivariable adjustment. Other complication rates did not differ significantly between cohorts. Round and shaped implants experienced similar 2-year patient-reported outcome scores.

CONCLUSIONS

This prospective, multicenter study is the largest evaluating outcomes of shaped versus round implants in breast reconstruction. Although recipients of round implants demonstrated lower infection rates compared with shaped implants, these patients were more likely to undergo contralateral symmetry procedures. Both implant types yielded comparable patient-reported outcome scores. With appropriate patient selection, both shaped and round implants can provide acceptable outcomes in breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Panniculus morbidus: obesity-related abdominal wall lymphoedema

A 52-year-old female patient presented with a massive abdominal wall swelling that adversely affected her lifestyle. Imaging revealed significant subcutaneous oedema and the presence of grossly distended veins. Subsequently, she underwent a 'toilet' panniculectomy and abdominoplasty. We describe the surgical technique used to retract the lymphoedematous tissue facilitating excisional surgery, and discuss the pathophysiology of this condition and the possible contribution of venous obstruction to the development of subcutaneous oedema.

Expression of autophagy-associated proteins in papillary thyroid carcinoma

The present study was designed to assess the protein expression of the autophagy-associated genes, Beclin-1 and microtubule-associated protein 1 light chain 3 (LC3)-II, as well as the association with clinicopathological features in papillary thyroid carcinoma (PTC). A total of 50 subjects were recruited, including 50 human PTC samples and paired adjacent noncancerous tissue samples. The protein expression of Beclin-1 and LC3-II was analyzed using immunohistochemistry and western blotting. Beclin-1 and LC3-II expression in PTC tissues significantly reduced compared with normal tissues (P<0.05). Expression of Beclin-1 and LC3-II was associated with lymph node metastasis of PTC (P<0.05), but had no association with age, gender, tumor size, tumor number and Tumor-Node-Metastasis stage (P>0.05). Expression of Beclin-1 and LC3-II were positively correlated (r=0.327;P=0.020) in PTC. In conclusion, the activity of autophagy was declined in PTC; this decrease in autophagic capacity may be associated with tumorigenesis and the development of PTC.

New era of electronic brachytherapy

Traditional brachytherapy refers to the placement of radioactive sources on or inside the cancer tissues. Based on the type of sources, brachytherapy can be classified as radionuclide and electronic brachytherapy. Electronic brachytherapy uses miniaturized X-ray sources instead of radionuclides to deliver high doses of radiation. The advantages of electronic brachytherapy include low dose to organs at risk, reduced dose to treating staff, no leakage radiation in off state, less shielding, and no radioactive waste. Most of these systems operate between 50 and 100 kVp and are widely used in the treatment of skin cancer. Intrabeam, Xoft and Papillon systems are also used in the treatment of intra-operative radiotherapy to breast in addition to other treatment sites. The rapid fall-off in the dose due to its low energy is a highly desirable property in brachytherapy and results in a reduced dose to the surrounding normal tissues compared to the Ir-192 source. The Xoft Axxent brachytherapy system uses a 2.25 mm miniaturized X-ray tube and the source almost mimics the high dose rate Ir-192 source in terms of dose rate and it is the only electronic brachytherapy system specifically used in the treatment of cervical cancers. One of the limiting factors that impede the use of electronic brachytherapy for interstitial application is the source dimension. However, it is highly anticipated that the design of miniaturized X-ray tube closer to the dimension of an Ir-192 wire is not too far away, and the new era of electronic brachytherapy has just begun.

Quality of life in thyroid cancer patients: a literature review

INTRODUCTION

Quality of life (QoL) has received increasing interest in the last years, especially in patients with cancer. This article aims to analyze a selection of medical research papers regarding the quality of life in patients with thyroid carcinoma. We overviewed the main QoL aspects derived from several studies and highlighted those less researched issues, which could represent a solid base for future clinical studies.

METHOD

We used an integrative selection method of medical literature, choosing mostly "free access" studies, as it was considered that they could be easily viewed, searched and researched including by patients.

RESULTS

After an integrative literature review, we selected 16 relevant studies. Patients with thyroid cancer have several factors influencing their QoL, with both physical and psychological impact. The decisive factors are the quality of the surgical act, radioiodine therapy, follow-up using rh-TSH vs. hormonal withdrawal, access to behavioral help and the relationship with their physician.

CONCLUSION

We must understand the emotional impact of the cancer diagnosis on the patient and we must collaborate in order to help the patient restore the psychosomatic balance and to recover the quality of life.

Is there still a role for the hepatic locoregional treatment of metastatic neuroendocrine tumors in the era of systemic targeted therapies?

Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) frequently present with distant metastases at the time of diagnosis and the liver is the most frequent site of spreading. The early identification of metastatic disease represents a major prognostic factor for GEP-NENs patients. Radical surgical resection, which is feasible for a minority of patients, is considered the only curative option, while the best management for patients with unresectable liver metastases is still being debated. In the last few years, a number of locoregional and systemic treatments has become available for GEP-NEN patients metastatic to the liver. However, to date only a few prospective studies have compared those therapies and the optimal management option is based on clinical judgement. Additionally, locoregional treatments appear feasible and safe for disease control for patients with limited liver involvement and effective in symptoms control for patients with diffuse liver metastases. Considering the lack of randomized controlled trials comparing the locoregional treatments of liver metastatic NEN patients, clinical judgment remains key to set the most appropriate therapeutic pathway. Prospective data may ultimately lead to more personalized and optimized treatments. The present review analyzes all the locoregional therapy modalities (i.e., surgery, ablative treatments and transarterial approach) and aims to provide clinicians with a useful algorithm to best treat GEP-NEN patients metastatic to the liver.

Effects of LncRNA-HOST2 on cell proliferation, migration, invasion and apoptosis of human hepatocellular carcinoma cell line SMMC-7721

The present study explored the effect of long non-coding RNA-human ovarian cancer-specific transcript 2 (LncRNA-HOST2) on cell proliferation, migration, invasion and apoptosis of human hepatocellular carcinoma (HCC) cell line SMMC-7721. HCC tissues and adjacent normal tissues from 162 HCC patients were collected. The HCC cell lines were assigned into the control group (regular culture), negative control (NC) group (transfected with siRNA) and experimental group (transfected with Lnc-HOST2 siRNA). Quantitative real-time PCR (qRT-PCR) was used to detect the expression of LncRNA-HOST2. Cell proliferation was detected by CCK-8 and colony-forming assays, cell apoptosis by flow cytometry and cell migration by Scratch test. Transwell assay was used to evaluate cell migration and invasion abilities. LncRNA-HOST2 expression in the HCC tissues increased 2-10 times than that in the adjacent normal tissues. Compared with the HL-7702 cell line, LncRNA-HOST2 expression in HepG2, SMMC-7721 and Huh7 cell lines was all up-regulated, but the SMMC-7721 cell had the highest Lnc-HOST2 expression. The LncRNA-HOST2 expression in the experimental group was down-regulated as compared with the control and NC groups. In comparison with the control and NC groups, cloned cells reduced, cell apoptosis increased, clone-forming ability weakened and inhibitory rate of colony formation increased in the experimental group. The cells migrating and penetrating into the transwell chamber were fewer in the experimental group than those in the control and NC groups. The experimental group exhibited slow wound healing and decreased cell migration area after 48 h. These findings indicate that LncRNA-HOST2 can promote cell proliferation, migration and invasion and inhibit cell apoptosis in human HCC cell line SMMC-7721.

Rhopalurus junceus scorpion venom induces apoptosis in the triple negative human breast cancer cell line MDA-MB-231

Rhopalurus junceus scorpion venom has demonstrated high cytotoxic activity in epithelial cancer cells. In the present study, the effect of scorpion venom on cell viability and apoptosis was evaluated in the MDA-MB-231 human breast carcinoma cell line. Cell viability was analyzed using MTT assay. The cell death event was examined trough end-point RT-PCR to identify the expression of apoptosis-related genes, fluorescent microscopy and mitochondrial membrane potential (ΔΨm) alteration. The results demonstrated that scorpion venom induced apoptosis in MDA-MB-231 cells in a time-dependent manner. Besides, scorpion venom treatment also resulted in p53, bax, noxa, puma, caspase 3 and p21 over-expression, while the expression of bcl-2 and bcl-xl was down-regulated. Apoptosis was associated with depolarization of ΔΨm. The overall effect indicates that the selective cytotoxic effect of the scorpion venom is associated with its apoptosis-inducing effect through the mitochondrial pathway. Therefore, R. junceus scorpion venom may be an interesting natural extract for further investigation in breast cancer treatment strategies.

A New Local Flap Nipple Reconstruction Technique Using Dermal Bridge and Preoperatively Designed Tattoo

Supplemental Digital Content is available in the text.

Background:

Nipple–areolar reconstruction is the final step in breast reconstruction. Reconstruction using local flaps and tattooing is useful in cases of bilateral reconstruction, a small nipple–areolar complex (NAC) as the donor site, and avoiding disturbance of the normal side and other body parts. However, this method can cause projection loss and color fading of the nipple. Moreover, the breast mound is reconstructed with an implant.

Methods:

We performed nipple–areolar reconstruction of 90 nipples using clover-designed flaps oriented at 120 degrees and tattooing after breast silicone implantation in 64 women. The tattoo was designed before flap operation and stained darker. Following donor site closure, a dermal flap was made as a bridge for nipple support. The nipple space was separated by the dermal flap from the breast mound and was filled with subcutaneous tissue. The size of the reconstructed nipple projection was measured postoperatively and 1 year later. The projection maintenance rate was calculated.

Results:

The heights of the nipple projection were 11.3 ± 1.8 mm (95% confidence interval [CI]: 10.9–11.7) just after the operation and 6.09 ± 2.4 mm (95% CI: 5.6–6.6) 1 year later. The actual range of nipple projection between these 2 heights was 5.2 ± 2.4 mm (95% CI: 4.7–5.7). The maintenance rate of the reconstructed nipple projection after 12 months was 54.1 ± 20.9 (95% CI: 49.7–58.5). The nipple color was maintained for over a year.

Conclusions:

Our nipple–areolar reconstruction technique could maintain the projection and color of the reconstructed nipple for a long period. Good outcomes were obtained in this implant-based breast reconstruction.

Role of prophylactic central neck dissection in clinically node-negative differentiated thyroid cancer: assessment of the risk of regional recurrence

Prophylactic central neck dissection in clinically node-negative patients remains controversial. The aim of this multicenter retrospective study was to determine the rate of metastases in the central neck in clinically node-negative differentiated thyroid cancer patients, to examine the morbidity, and to assess the risk of regional recurrence in patients treated with total thyroidectomy with concomitant bilateral or ipsilateral central neck dissection compared with those undergoing total thyroidectomy alone. 258 consecutive clinically node-negative patients were divided into three groups according to the procedures performed: total thyroidectomy only (group A), total thyroidectomy with concomitant ipsilateral central neck dissection (group B), and total thyroidectomy combined with bilateral central neck dissection (group C). Mean operative time and postoperative stay were shorter in Group A (p < 0.01). The incidence of postoperative transient hypoparathyroidism was lower in Group A (p = 0.03), whereas no differences in the incidence of permanent hypoparathyroidism and nerve palsy were present. Postoperative radioactive iodine administration was higher in group B and particularly C (p = 0.03) compared with group A. There were no statistically significant differences in terms of regional recurrence. Differentiated thyroid cancer has a high rate of central lymph node metastasis even in clinically node-negative patients; in the present study there was no statistically significant difference in the rates of locoregional recurrence between the three modalities of treatment. Total thyroidectomy appears to be an adequate treatment for clinically node-negative differentiated thyroid cancer. Prophylactic central neck dissection might be considered for differentiated thyroid cancer patients with large tumor size or extrathyroidal extension.

Transoral endoscopic thyroidectomy: preliminary experience in Italy

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a feasible novel surgical procedure that does not need visible incisions. We describe our initial experience with TOETVA. We recruited 15 patients who were willing to undergo TOETVA. Inclusion criteria were (a) patients who had a neck ultrasound (US) with a estimated thyroid diameter not larger than 10 cm; (b) US estimated gland volume ≤45 mL; (c) nodule size ≤50 mm; (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (e) follicular neoplasm; (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through a three-port technique placed at the oral vestibule, one 10-mm port for 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO₂ insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments and intraoperative neuromonitoring. There were 34% total thyroidectomies and 66% hemithyroidectomies. All TOETVA procedures were performed successfully with no conversions. The mean operative time was 87.6 (59-118) min for lobectomy and 107.6 (99-135) min for bilateral procedure. We observed one case of transient postoperative hypocalcemia. There was no recurrent laryngeal nerve palsy. The cosmetic result was excellent in all patients. This is the first case series of TOETVA in Italy. TOETVA may provide a method for ideal cosmetic results. The results are encouraging, and we are optimistic about the future expansion of its applicability.

Making decisions about breast reconstruction: A systematic review of patient-reported factors influencing choice

PURPOSE

Many studies have explored women's reasons for choosing or declining a particular type of breast reconstruction (BR) following mastectomy for breast cancer. This systematic review synthesises women's reasons for choosing a range of BR options, including no BR, in different settings and across time.

METHODS

Thirteen databases were systematically searched, with 30 studies (4269 participants), meeting the selection criteria. Information on study aim and time frame, participation rate, design/methods, limitations/bias, reasons and conclusions, as well as participant clinical and demographic information, was reported. An overall quality score was generated for each study. Reasons were grouped into eight domains.

RESULTS

While study methodology and results were heterogeneous, all reported reasons were covered by the eight domains: Feeling/looking normal; Feeling/looking good; Being practical; Influence of others; Relationship expectations; Fear; Timing; and Unnecessary. We found a strong consistency in reasons across studies, ranging from 52% of relevant publications citing relationship expectations as a reason for choosing BR, up to 91% citing fear as a reason for delaying or declining BR. Major thematic findings were a lack of adequate information about BR, lack of genuine choice for women and additional access limitations due to health system barriers.

CONCLUSIONS

Understanding women's reasons for wanting or not wanting BR can assist clinicians to help women make choices most aligned with their individual values and needs. Our thematic findings have equity implications and illustrate the need for surgeons to discuss all clinically appropriate BR options with mastectomy patients, even if some options are not available locally.

PanIN Neuroendocrine Cells Promote Tumorigenesis via Neuronal Cross-talk

Nerves are a notable feature of the tumor microenvironment in some epithelial tumors, but their role in the malignant progression of pancreatic ductal adenocarcinoma (PDAC) is uncertain. Here, we identify dense innervation in the microenvironment of precancerous pancreatic lesions, known as pancreatic intraepithelial neoplasms (PanIN), and describe a unique subpopulation of neuroendocrine PanIN cells that express the neuropeptide substance P (SP) receptor neurokinin 1-R (NK1-R). Using organoid culture, we demonstrated that sensory neurons promoted the proliferation of PanIN organoids via SP-NK1-R signaling and STAT3 activation. Nerve-responsive neuroendocrine cells exerted trophic influences and potentiated global PanIN organoid growth. Sensory denervation of a genetically engineered mouse model of PDAC led to loss of STAT3 activation, a decrease in the neoplastic neuroendocrine cell population, and impaired PanIN progression to tumor. Overall, our data provide evidence that nerves of the PanIN microenvironment promote oncogenesis, likely via direct signaling to neoplastic neuroendocrine cells capable of trophic influences. These findings identify neuroepithelial cross-talk as a potential novel target in PDAC treatment. Cancer Res; 77(8); 1868-79. ©2017 AACR.

The current state of intermittent intraoperative neural monitoring for prevention of recurrent laryngeal nerve injury during thyroidectomy: a PRISMA-compliant systematic review of overlapping meta-analyses

Purpose

Recurrent laryngeal nerve (RLN) injury is one of the most common and detrimental complications following thyroidectomy. Intermittent intraoperative nerve monitoring (I-IONM) has been proposed to reduce prevalence of RLN injury following thyroidectomy and has gained increasing acceptance in recent years.

Methods

A comprehensive database search was performed, and data from eligible meta-analyses meeting the inclusion criteria were extracted. Transient, permanent, and overall RLN injuries were the primary outcome measures. Quality assessment via AMSTAR, heterogeneity appraisal, and selection of best evidence was performed via a Jadad algorithm.

Results

Eight meta-analyses met the inclusion criteria. Meta-analyses included between 6 and 23 original studies each. Via utilization of the Jadad algorithm, the selection of best evidence resulted in choosing of Pisanu et al. (Surg Res 188:152–161, 2014). Five out of eight meta-analyses demonstrated non-significant (p > 0.05) RLN injury reduction with the use of I-IONM versus nerve visualization alone.

Conclusions

To date, I-IONM has not achieved a significant level of RLN injury reduction as shown by the meta-analysis conducted by Pisanu et al. (Surg Res 188:152–161, 2014). However, most recent developments of IONM technology including continuous vagal IONM and concept of staged thyroidectomy in case of loss of signal on the first side in order to prevent bilateral RLN injury may provide additional benefits which were out of the scope of this study and need to be assessed in further prospective multicenter trials.

Electronic supplementary material

The online version of this article (doi:10.1007/s00423-017-1580-y) contains supplementary material, which is available to authorized users.

Lenvatinib enhances the antitumor effects of paclitaxel in anaplastic thyroid cancer

Anaplastic thyroid cancer (ATC) is a rare malignancy and has a very poor prognosis due to its aggressive behavior and resistance to treatment. No effective treatment modalities are currently available. Lenvatinib has shown encouraging results in the patients with radioiodine-refractory differentiated thyroid cancer (DTC); however, lenvatinib monotherapy has a relatively low efficacy against ATC. In this study, we assessed the antitumor effects of a combination of lenvatinib and microtubule inhibitor paclitaxel in ATC cells in vitro and in vivo. Our data showed that lenvatinib monotherapy was less effective than paclitaxel monotherapy in ATC cell lines and xenografts. The addition of lenvatinib to paclitaxel synergistically inhibited colony formation and tumor growth in nude mice, and induced G2/M phase cell cycle arrest and cell apoptosis as compared to lenvatinib or paclitaxel monotherapy. Taken together, this is the first study to suggest that lenvatinib/paclitaxel combination may be a promising candidate therapeutic strategy for ATC.

Lymph Node Metastases in Papillary and Medullary Thyroid Carcinoma Are Independent of Intratumoral Lymphatic Vessel Density

BACKGROUND

Blood and lymph vessel invasion are well-recognized markers of tumor aggressiveness, as these are the routes that lead to metastases. Thyroid tumors, depending on the histological variant, tend to have distinctive biological behaviors and use different vascular routes to metastasize, yet the mechanisms underlying the metastatic process are still poorly understood.

OBJECTIVES

The aim of this study was to assess how the lymph vessel density (LVD) in different histological types of thyroid tumors, and in their surrounding tissue, correlate with the presence of lymph node metastases (LNM) and tumor pathological features.

METHODS

Lymph vessels of papillary thyroid carcinomas (PTC), of the classical (CVPTC, n = 50) and follicular variants (FVPTC, n = 18), and medullary thyroid carcinomas (MTC, n = 34) were immunohistochemically stained against antigen D2-40. The stained area was quantified using a computerized morphometric analysis tool and correlated with the tumor pathological characteristics.

RESULTS

LVD within all analyzed thyroid tumor subtypes was significantly lower than in the surrounding thyroid tissues (p < 0.001). Despite intratumoral LVD being significantly higher in CVPTC than in FVPTC, and peritumoral LVD being significantly higher in MTC than in PTC (p < 0.05), no correlations were found between LVD (either intratumoral or peritumoral) and the presence of lymph node metastasis.

CONCLUSIONS

As no LVD differences were found amongst thyroid tumors with or without LNM, dissemination is more likely to depend on the tumor ability to invade the abundant lymph vessel network of the surrounding thyroid tissue than on the ability of the tumor to promote de novo lymphangiogenesis.

Emerging Roles for MicroRNAs in Diabetic Microvascular Disease: Novel Targets for Therapy

Chronic, low-grade systemic inflammation and impaired microvascular function are critical hallmarks in the development of insulin resistance. Accordingly, insulin resistance is a major risk factor for type 2 diabetes and cardiovascular disease. Accumulating studies demonstrate that restoration of impaired function of the diabetic macro- and microvasculature may ameliorate a range of cardiovascular disease states and diabetes-associated complications. In this review, we focus on the emerging role of microRNAs (miRNAs), noncoding RNAs that fine-tune target gene expression and signaling pathways, in insulin-responsive tissues and cell types important for maintaining optimal vascular homeostasis and preventing the sequelae of diabetes-induced end organ injury. We highlight current pathophysiological paradigms of miRNAs and their targets involved in regulating the diabetic microvasculature in a range of diabetes-associated complications such as retinopathy, nephropathy, wound healing, and myocardial injury. We provide an update of the potential use of circulating miRNAs diagnostically in type I or type II diabetes. Finally, we discuss emerging delivery platforms for manipulating miRNA expression or function as the next frontier in therapeutic intervention to improve diabetes-associated microvascular dysfunction and its attendant clinical consequences.

Level I lymph node involvement in patients with N1b papillary thyroid carcinoma: a prospective study

Most of the studies on the incidence, pattern, and predictive factors of lymph node (LN) metastasis with papillary thyroid carcinoma (PTC) have been performed retrospectively and no common consensus has been reached regarding the predictors for the involvement of level I LNs. This study was conducted prospectively to determine the incidence and the possible predictors of level I involvement in N1b PTC patients. The study included 30 consecutive patients with N1b stage of PTC. All the patients underwent neck dissection (ND) including level I. The relation between involvement of level I LNs and various clinicopathological variables was studied. Unilateral neck dissection was performed in 24 patients and bilateral neck dissection in six patients leading to 36 NDs. Level I was excised in all patients, with five specimens (14%) positive for metastasis. Levels II, III, IV, V, VI, and VII were positive in 52.8, 58.3, 58.3, 33.3, 63, and 22.2%, respectively. Level I involvement was significantly related to the number of lymph node levels affected (p = 0.003) and macroscopic extranodal invasion (p = 0.04). It was not related to the involvement of other individual levels, gender, age, size of the largest thyroid nodule, size of the largest LN involved, or histo-pathological variant of the tumor. This study suggests that including level I in therapeutic neck dissection for N1b PTC patients might be recommended in selected cases of multiple level involvement and macroscopic extranodal invasion requiring sacrifice of internal jugular vein, spinal accessory nerve, or sternomastoid muscle.