The role of intraoperative frozen section of central neck lymph nodes in the management of patients preoperatively diagnosed with low- risk differentiated cancer

INTRODUCTION

Histological examination during surgery (FS) has a place in the surgical management of differentiated thyroid carcinoma (DTC). Extending the indication for limited surgery to 4 cm tumor size (ATA guidelines 2015) cytologically verified DTCs, increases the emphasis on accurate patient selection. In our work, we reflected on the effectiveness of FS and its relationship to optimal patient management.

METHODS

In a single-center retrospective study, we evaluated the documentation of patients indicated for primary surgery for DTC from January 1, 2016 to December 31, 2020 - there was 489 patients collectively, 121 were men, median age was 50 years (1681), 73 patients (female, age 1845 years) with preoperatively identified low-risk DTC (size 1140mm) were indicated for lobectomy.

RESULTS

34 patients (46.6%) did not meet the criteria for limited surgery 15 patients were identified from FS of the lymph nodes of the central compartment (LNCK) (15 of 25 patients) - 1 patient with false negative result and 6 patients with FS of the thyroid gland (SH) (6 / 41) - 11 patients with false negative findings. Two-step OP surgery was performed on 13 patients (17.8%). FS of LNCK identified high-risk cancer and reduced the risk of two-step surgery compared to the group of patients in whom FS was not performed or was performed from thyroid gland. The difference was statistically significant (OR 1.93, p=0.026).

CONCLUSION

Approximately ½ of the patients from preoperatively identified low-risk cancers in our cohort met the criteria for limited surgery. About 30% of them eventually needed a two-step operation. Perioperative examination of LNCK helps to perform radical surgery at one time.

Predictive model using hemoglobin, albumin, fibrinogen, and neutrophil-to-lymphocyte ratio to distinguish patients with colorectal cancer from those with benign adenoma

Colorectal cancer (CRC) is associated with inflammation, activation of coagulation, and mild anemia. Hematological parameters reflecting ongoing cancer may have the potency to be effective for early diagnostics of CRC. The aim of this study was to examine the validity and relationship between some biochemical and hematological parameters for the early diagnosis of CRC. We designed a prospective observational cohort study to analyze whether these laboratory markers have the potency to distinguish benign tumors from malignant before planned surgery. The clinical data were collected from 208 patients with suspected benign or malignant colorectal tumors who were eligible for elective surgery between September 2018 and January 2020. Blood samples were collected one day before surgery, examined parameters included: complete blood count, hemoglobin (HGB) concentration, albumin (ALB), C-reactive protein (CRP), interleukin-6 (IL-6), and fibrinogen (FG). Absolute neutrophil and lymphocyte counts were used for the calculation of the neutrophil-to-lymphocyte ratio (NLR). The diagnosis was confirmed by histopathological examination. The 197 patients were divided into the group of benign (B group = 52 patients) or malignant tumors (CRC group = 145 patients). ROC curves and cut-off values of NLR, HGB, FG, and ALB concentration, serum CRP and IL-6 levels. In the cohort of 197 adult patients submitted for the elective colorectal surgery the complete blood samples drawn one day before surgery showed significant differences between patients with benign tumors and colorectal carcinoma: HGB (mean 139.9 g/l vs. 129.9; P < 0.001), FG (mean 3.36 g/l vs. 3.94 g/l; P < 0.001), ALB (mean 43.4 g/l vs. 41.1 g/l; P = 0.001), NLR (mean 2.73 vs. 3.88; P = 0.016), respectively. CRP (mean 2.9 mg/l vs. 4.4 mg/l; P = 0.011), thrombocyte count (mean 235×109/l vs. 265×109/l; P < 0.029). Differences in IL-6 concentrations were not significant (2.9 pg/ml vs. 4.15 pg/ml; P = 0.052). Using multivariable logistic regression analysis four valid parameters (HGB, FG, ALB, and NLR) were suitable for the construction of a diagnostic predictive model for the identification of CRC. In conclusion, a panel of routinely examined blood parameters like HGB, FG, ALB, and NLR has the potency to distinguish patients with benign tumors from malignant by applying a diagnostic predictive model for early laboratory detection of CRC.

Pretreatment Levels of Chromogranin A and Neuron-specific Enolase in Patients With Gastroenteropancreatic Neuroendocrine Neoplasia

BACKGROUND/AIM

Chromogranin A (CgA) and neuron-specific enolase (NSE) are applied in the diagnosis of neuroendocrine neoplasms (NENs), especially non-functional ones. The aim of this study was to investigate the predictive values of CgA and NSE in long-term survival.

PATIENTS AND METHODS

Our retrospective analysis included 65 patients with histologically verified gastroenteropancreatic NEN between 2005 and 2019. We performed bivariate and multivariable analyses to evaluate the relationship between CgA and NSE values before histological assessment and overall survival. Distribution of time-to-event was analyzed using Kaplan-Meier survival curves and modelled by Cox regression models.

RESULTS

Elevated NSE levels prior to histology were significantly associated with worse survival (HR=1.13, p=0.004) and were associated with low-differentiated NENs (r_s=0.321, p=0.0338). CgA was associated with well-differentiated tumors (r_s=0.233), but not significantly.

CONCLUSION

Pretreatment serum levels of NSE can serve as a valuable additional predictor of long-term survival in patients with NEN.

A randomized clinical trial of technical modifications of appendix stump closure during laparoscopic appendectomy for uncomplicated acute appendicitis

Background

Closure of the appendix stump presents the most critical part of laparoscopic appendectomy. The aim of the present study was to compare the medical outcomes and cost analysis of laparoscopic appendectomy with respect to the different methods of stump closure.

Methods

This was a prospective randomized clinical trial conducted in a single institution (University Hospital Ostrava) within a 2-year study period. All included patients were randomized into one of three trial arms (endoloop, hem-o-lok clips or endostapler).

Results

In total, 180 patients (60 patients in each arm) were enrolled into the study. The mean length of hospital stay (3.6 ± 1.7 days) was comparable in all study arms. The shortest operative time was noted in the hem-o-lok subgroup of patients (37.9 ± 12.5 min). Superficial surgical site infection was detected in 4.4% of study patients; deep surgical site infection was noted in 1.7% of the patients. The frequency of surgical site infections was comparable in all study arms (p = 0.7173). The mean direct costs of laparoscopic appendectomy were significantly the lowest in the hem-o-lok subgroup of patients. Laparoscopic appendectomy is not a profit-making procedure in our institution (mean profit of made from the study patients was—104.3 ± 579.2 Euro). Closure of the appendix stump by means of endostapler presents the most expensive and the highest loss-incurring technique (p = 0.0072).

Conclusions

The present study indicates that all technical modifications of appendix stump closure are comparable with regards to postoperative complications. The stapler technique is significantly the most expensive. We concluded that hem-o-lok clips have the potential for becoming the preferred method of securing the appendix base during laparoscopic appendectomy. Trial registration NCT03750032 (http://www.clinicaltrials.gov).

The role of subtotal and total gastrectomy in the treatment of gastric cancer

The optimal procedure for the lower third gastric adenocarcinoma is still an open question. We performed an analysis of the long-term survival of patients after subtotal (SG) or total gastrectomy (TG) on 164 enrolled patients. Bivariate and multivariable analyses were performed in order to identify characteristics associated with long-term survival. Survival was significantly affected by the number of positive lymph nodes (LN). Patients who have undergone TG had a higher number of total removed LN. The adjusted hazard ratio for the TG group suggests a partial superiority of TG over SG for patients with curative intent. Our data support the importance of extended LN dissection.

Diagnostic ipsilateral central neck dissection may reduce undertreatment of initially low-risk papillary thyroid cancer

Although small papillary thyroid cancer (PTC) patients are considered as low-risk population, approximately 5-20% of these patients relapse after surgery. The objective of this single-center retrospective study was to identify risk factors, which could help to distinguish patients who would need additional treatment after surgery. A total of 268 patients (39 men, 229 women, median age 49 years) underwent surgery between 2007-2015, and fulfilled inclusion criteria: tumor size ≤20 mm, absence of metastatic lymph nodes (LN) in the lateral neck compartment (LC), and absence of local invasion. Total thyroidectomy was performed in 252 cases, in 221 cases with central neck compartment (CC) dissection. The outcome - a more aggressive disease - was defined as the presence of metastases in the LNLC or in distant organs found during follow-up. A median follow-up was 117 months. Overall, 41 patients experienced the outcome with a median time-to-event of 18 months. Male gender (OR=2.2, p=0.049), extra-thyroidal extension ETE (OR=2.61, p=0.015), and metastases in LNCC (OR=4.21, p<0.001) were associated with worse outcome. Multivariable analysis and stratification according to ETE revealed an effect modification with a higher effect of the positive LNCC on the outcome among patients without ETE than in those with ETE. Our findings advocate placing greater emphasis on the role of LNCC metastases in the absence of ETE. In clinically node-negative tumors intraoperative examination of CC on the side of the tumor followed by CC dissection if metastatic lymphadenopathy is present could play an important role in the stratification of patients with small-size PTC.

Applications of magnetoliposomes with encapsulated doxorubicin for integrated chemotherapy and hyperthermia of rat C6 glioma

There is substantial evidence regarding enhanced antitumor cytotoxicity of selected chemotherapeutic agents by appropriate heat exposure (40–44°C). Based upon these results, the integration of hyperthermia as an additional treatment modality given simultaneously with systemic chemotherapy is currently of considerable interest. Hyperthermia can be induced by alternating magnetic field and magnetic nanoparticles. Thus, we have used thermosensitive magnetoliposomes that contained superparamagnetic iron oxide nanoparticles and doxorubicin for in vitro and in vivo therapy of rat glioma C6. The results showed that magnetoliposomes can be specifically heated to 43°C (phase transition temperature of a used lipid composition) in a few minutes, and during this, the encapsulated doxorubicin is released in a controllable manner. The in vitro experiments showed that the cell viability decreased to 79.2% after heat treatment alone and to 47.4% for doxorubicin-loaded magnetoliposomes without application of alternating magnetic field, while the combined treatment resulted in 17.3% cell viability. Also, in vivo results demonstrated that magnetic drug targeting has a strong antiglioma effect with a tumor volume growth inhibition and complete regression. Such targeted delivery and controlled release of anticancer agents would provide clinical advantages compared with currently available methods.

Application of cationized magnetoferritin for magnetic field-assisted delivery of short interfering RNA in vitro

Cationized magnetoferritin is used for development of a simple, efficient, and fast delivery of short interference RNA into cells using combination of magnetophoresis for pre-concentration of siRNA-magnetoferritin complex on the surface of plated cells with subsequent application of nanosecond laser pulses producing stress waves in transfection chamber, which permeabilize cell membrane for the facilitated delivery of siRNA into the cell interior. As has been quantified using siRNA inducing cell death assay, by combination of these two physical factors we have obtained high efficiency for tested three different human carcinoma cells. Proposed method of gene silencing based on cationized magnetoferritin is a versatile and easily accessible platform with many possible applications in gene therapy.

Application of Albumin-embedded Magnetic Nanoheaters for Release of Etoposide in Integrated Chemotherapy and Hyperthermia of U87-MG Glioma Cells

BACKGROUND/AIM

Malignant gliomas remain refractory to several therapeutic approaches and the requirement for novel treatment modalities is critical to combat this disease. Etoposide is a topoisomerase-II inhibitor, which promotes DNA damage and apoptosis of cancer cells. In this study, we prepared albumin with embedded magnetic nanoparticles and etoposide for in vitro evaluation of combined hyperthermia and chemotherapy.

MATERIAL AND METHODS

Magnetic nanoparticles were prepared by a modified co-precipitation method in the presence of human serum albumin and etoposide. A cellular proliferation assay was used to determine the effects of these nanostructures on the viability of U87 glioma cells in an alternating magnetic field.

RESULTS

The in vitro experiments showed that cell viability decreased to 59.4% after heat treatment alone and to 53.8% on that with free etoposide, while combined treatment resulted in 7.8% cell viability.

CONCLUSION

Integrating hyperthermia and chemotherapy using albumin co-embedded magnetic nanoheaters and etoposide may represent a promising therapeutic option for glioblastoma.

Fibrinogen Levels Are Associated with Lymph Node Involvement and Overall Survival in Gastric Cancer Patients

BACKGROUND/AIM

Combination of perioperative chemotherapy with gastrectomy with D2 lymphadenectomy improves long-term survival in patients with gastric cancer. The aim of this study was to investigate the predictive value of preoperative levels of CRP, albumin, fibrinogen, neutrophil-to-lymphocyte ratio and routinely used tumor markers (CEA, CA 19-9, CA 72-4) for lymph node involvement.

MATERIALS AND METHODS

This retrospective study was conducted in 136 patients who underwent surgery between 2007 and 2015. Bivariable and multivariable analyses were performed in order to identify important characteristics associated with the risk of lymph node involvement. Kaplan-Meier survival curves and log-rank tests were used to compare overall survival.

RESULTS

Lymph node involvement was significantly affected by preoperative fibrinogen (p=0.008) and albumin (p=0.023). Poor clinical condition, T and N staging and fibrinogen level above 3.5 g/l were significantly associated with worse overall survival.

CONCLUSION

Preoperative fibrinogen and albumin levels are significantly associated with lymphoid metastases in patients with gastric cancer.

[Total duodenopancreatectomy for renal cell carcinoma metastases - case report]

INTRODUCTION

The frequency of pancreatic metastases ranges from 2% to 5%. Pancreas is an elective site for metastases from renal carcinoma. Pancreatic metastases from renal cell carcinoma are frequently the only metastatic site and they typically occur in the seventh decade of life.

CASE REPORT

We report 1 female patient (aged 58 years) with multifocal and isolated pancreatic metastases of renal cell carcinoma. Total duodenopancreatectomy was performed.

CONCLUSION

In selected cases, pancreatic resection due to renal cell cancer metastases is deemed indicated, improving overall patient survival.

KEY WORDS

renal cell carcinoma (RCC) isolated pancreatic metastases total duodenopancreatectomy.

Sertoli-Leydig cell tumor of the ovary--morphological and immunohistochemical analysis

Sertoli-Leydig cell tumor is a rare and usually unilateral tumor of the ovary occurring in women's reproductive age. Only about 10% of these patients are over 50 years of age. One third of these patients are suffering from signs of virilisation. This work summarizes the morphological and immunohistochemical characteristics of this tumor in a 56-year old woman with clinical signs of virilisation.