Radiotherapy and Breast Reconstruction: What Is the Ideal Timing? A Narrative Review

INTRODUCTION

Women undergoing mastectomy choose to pursue breast reconstruction (BR) in order to reduce their body image distress.Adjuvant chest wall irradiation is associated with a negative cosmetic outcome. The aim of our review was to identify the optimal timing of BR relating to radiotherapy delivery.

MATERIALS AND METHODS

Using Cochrane Library, Embase, PubMed, Springer, Wanfang and CNKI, we performed a non-systematic review of articles published up to August 2021.

RESULTS

There is no hard evidence in favor of immediate, delayed or 2-stage BR when post-mastectomy radiation is indicated. Immediate and 2-stage BR seem to be valid alternatives to delayed BR.

CONCLUSIONS

Further research is essential in order to assess clinician and patient reported aesthetic outcomes and determine the optimal timing of BR in view of post-mastectomy radiotherapy, in breast cancer survivors.

Lymph Node Cellular Dynamics in Cancer and HIV: What Can We Learn for the Follicular CD4 (Tfh) Cells?

Lymph nodes (LNs) are central in the generation of adaptive immune responses. Follicular helper CD4 T (Tfh) cells, a highly differentiated CD4 population, provide critical help for the development of antigen-specific B cell responses within the germinal center. Throughout the past decade, numerous studies have revealed the important role of Tfh cells in Human Immunodeficiency Virus (HIV) pathogenesis as well as in the development of neutralizing antibodies post-infection and post-vaccination. It has also been established that tumors influence various immune cell subsets not only in their proximity, but also in draining lymph nodes. The role of local or tumor associated lymph node Tfh cells in disease progression is emerging. Comparative studies of Tfh cells in chronic infections and cancer could therefore provide novel information with regards to their differentiation plasticity and to the mechanisms regulating their development.

Utilizing Yoga in Oncologic Patients Treated with Radiotherapy: Review

Purpose:

Several trials on noncancer population indicate that yoga is associated with meaningful clinical effects. This study evaluated the physical and psychosocial outcomes of yoga in oncologic patients treated with radiotherapy.

Methods:

We focused on a research through Cochrane Register of Controlled Trials (CENTRAL), BioMed Central, and MEDLINE studies up to May 2017.

Results:

Yoga was found to have a substantial benefit in cancer patients’ distress, anxiety, and depression. It also demonstrated a moderate impact on fatigue and emotional function and a small and insignificant effect on functional well-being and sleep disturbances. As far as the effects on psychological outcomes are concerned, there was insufficient evidence.

Conclusions:

This systematic review of randomized controlled trials showed that yoga has strong beneficial effects on oncologic patients’ quality of life. Results of the current review must be interpreted with caution due to the relative small sample sizes of most of the included studies, while a prospective randomized study stands in need for the confirmation of our results.

Estimating the agreement between the metabolic rate calculated from prediction equations and from a portable indirect calorimetry device: an effort to develop a new equation for predicting resting metabolic rate

BACKGROUND

Many studies have been performed over time in order to determine the reliability of metabolic rate prediction equations.

PURPOSE

To evaluate the agreement, in terms of bias, absolute bias and accuracy between metabolic rate prediction equations and measured metabolic rate using indirect calorimetry system (IC), investigating also the factors affecting this agreement.

METHODS

The anthropometric features of 383 Caucasian participants of all Body Mass Index (BMI) classes were recorded and Resting Metabolic Rate (RMR) was measured by using the IC Fitmate portable device. The resulting values were compared with the predictive values of Harris & Benedict, Schofield, Owen, FAO-WHO-UNU, Mifflin and Harrington equations.

RESULTS

A closer approximation in agreement was obtained using the Harrington equation (based on BMI, age and gender). The equations using variables, such as weight, height, age and gender demonstrated higher agreement than the equations using merely weight and gender. Higher educational level was associated with normal weight, while higher calorific ratio was found in the class of normal-weighted individuals. An inverse relationship between ΒΜΙ and RMR was also observed and a logarithmic equation for calculating RMR was created, which was differentiated in relation to BMI classes, using the weight and gender variables.

CONCLUSION

A better measurement agreement between RMR prediction equations and IC may be achieved due to BMI consideration. The present findings contributed to a better understanding of the measured parameters, confirming the inverse relationship between BMI and RMR. Age group and gender variables may also exert significant role on the bias response of some RMR equations.

Magnetic resonance spectroscopy of the breast at 3T: pre- and post-contrast evaluation for breast lesion characterization

PURPOSE

To determine whether in vivo proton magnetic resonance spectroscopy at 3T can provide accurate breast lesion characterization, and to determine the effect of gadolinium on the resonance of tCho.

METHODS

Twenty-four positive-mammogram patients were examined on a 3T MR scanner. 1H-MRS was performed before and after gadolinium administration. tCho peak was qualitatively evaluated before and after contrast injection.

RESULTS

Fourteen out of 27 lesions proved to be malignant after histopathological diagnosis. Using 1H-MRS, before contrast injection, 6/14 confirmed malignancies and 11/13 benign lesions were correctly classified; while, after contrast injection, 11/14 confirmed malignancies and 12/13 benign processes were correctly classified. Post gadolinium 1H-MRS proved useful in picking up tCho signal, improving the overall accuracy, sensitivity, and specificity by 35%, 83%, and 9%, respectively.

CONCLUSION

1H-MRS overall accuracy, sensitivity, and specificity in detecting breast lesion's malignancy were increased after gadolinium administration. It is prudent to perform 1H-MRS before contrast injection in large breast lesions to avoid choline underestimation. In cases of small or non-mass lesions, it is recommended to perform 1H-MRS after contrast injection for better voxel prescription to enable a reliable preoperative diagnosis.

Clinical and biological characteristics of breast cancer

PURPOSE

in view of the crucial importance of early detection and diagnosis of breast cancer for subsequent treatment and prognosis, the aim of this study was to identify clinical and biological characteristics of breast cancer at the time of diagnosis.

METHODS

the study enrolled 449 breast cancer patients in Clinical Centre Nis. Results were analyzed using Student's t-test for paired and unpaired samples, chi-square test, Mantel- Haenszel test and Fisher's test of exact probability.

RESULTS

The average patient age was 56.2 ± 12 years (range 23-85). Seventyhorbar;three percent of the affected women were postmenopausal and 8.3% below 40 years of age. Operable disease was identified in 78% of the cases, and metastatic in 3.6%. TNM clinical stage IIA was identified in 27.6% of the patients, T2 in 49.2% and Tis in 0.9%. Almost 44% had negative axillary lymph nodes. Most common monolocalization of metastatic disease was the liver and the supraclavicular lymph nodes, and combined localization was the liver and bones. Histologic and nuclear grades 2 and ductal carcinoma were most common. Estrogen receptor positive (ER+) status was 3-fold higher than ER negative (ER-) status. Human epidermal growth factor receptor 2 (HER2) positive patients were most commonly ER-. The most common primary tumor site was the upper lateral quadrant. Left breast was more commonly involved. Radical surgery was the most common type of operation.

CONCLUSION

in view of the unfavorable age of patients at the time of diagnosis and clinical and biological tumor characteristics, the results confirmed that it is of vital importance to provide breast cancer prevention, screening, and to organize breast cancer units according EUSOMA guidelines.

Laparoscopic versus open appendectomy in men: a prospective randomized trial

BACKGROUND

The role of laparoscopic treatment in acute appendicitis still is unclear. Although some evidence in the literature suggests diagnostic benefits from laparoscopy for young women with suspected acute appendicitis, there is scepticism about the utility of this approach for men. This study aimed to compare open and laparoscopic appendectomy performed for men with suspected acute appendicitis.

METHODS

All male patients older than 15 years with an American Society of Anesthesiology (ASA) classification of 3 or less, no previous abdominal surgery, and no contraindication for pneumoperitoneum were prospectively randomized to undergo either open appendectomy (OA) or laparoscopic appendectomy (LA). The primary end point was a detected difference in postoperative hospital length of stay, and the secondary end points were detected differences in postoperative analgesia, morbidity, and length of the recovery period.

RESULTS

In this study, 147 men with suspected acute appendicitis were randomized to either OA (n = 75) or LA (n = 72). It took longer to perform LA (60 min; range, 20-120 min vs. 45 min; range, 20-90 min; p = 0.0027), and LA did not result in any significant difference for the parameters evaluated.

CONCLUSION

The postoperative length of hospital stay did not differ significantly between OA and LA for men. Laparoscopic appendectomy required more time and did not offer any advantages compared with OA.

Characterization of breast lesions with CE-MR multimodal morphological and kinetic analysis: comparison with conventional mammography and high-resolution ultrasound

OBJECTIVE

Evaluation of the diagnostic value of magnetic resonance mammography and comparison with conventional mammography and ultrasonography in cases of women with suspicious breast lesions.

SUBJECTS AND METHODS

Sixty-nine women (age range 39-68 years) with 78 focal breast lesions were examined with mammography, ultrasonography and dynamic magnetic resonance mammography. The lesions were classified according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon of the American College of Radiology for each diagnostic method. Histological reports were available after biopsy or surgical excision of the lesions.

RESULTS

Pathological examination confirmed that 53 lesions were malignant and 25 benign. Conventional mammography estimated a total of 59/78 lesions as malignant with 44 true positive lesions, ultrasonography estimated a total of 50/78 lesions as malignant with 44 true positive lesions and magnetic resonance mammography estimated a total of 66/78 lesions as malignant with 52 true positive lesions. Sensitivity and specificity of magnetic resonance mammography in the diagnosis of malignancy was 98.1% and 44%, of conventional mammography 83% and 40% and of ultrasonography 83% and 76%. Negative predictive value for magnetic resonance mammography was 91.7%, for ultrasonography 67.9% and for mammography 52.6% for malignancies.

CONCLUSION

Magnetic resonance mammography has the highest negative predictive value compared with mammography and ultrasound in cases of suspicious breast lesions. The combination of morphologic and enhancement criteria can improve the diagnostic capability of magnetic resonance mammography (MRM) in breast lesion characterization.

Low RLS prevalence and awareness in central Greece: an epidemiological survey

Restless legs syndrome (RLS) is a sensorimotor disorder with a general population prevalence of 3-10%. A single, previous epidemiological study performed in south-east Europe reported the lowest prevalence rate amongst European countries. We conducted a population-based survey of RLS in central Greece. A total of 4200 subjects were randomly recruited. We used the international RLS study group criteria for diagnosis and the severity scale for severity assessment in subjects with RLS. We also included questions to assess the level of awareness of RLS in our region. A total of 3033 subjects were screened. The overall lifetime prevalence was 3.9% with a female-to-male ratio of 2.6:1. Nearly half of RLS patients reported moderate to severe intensity of symptoms. After adjustment for multiple comparisons we found no association of RLS with education level, smoking, alcohol intake, caffeine consumption, shift work, professional pesticide use or comorbid illness. Our study revealed a low level of awareness amongst the population and physicians in our region and sub-optimal management. We provide further evidence for low prevalence of RLS in south-east Europe and a low level of awareness of RLS in our region.

Amiloride-sensitive sodium channels on the parietal human peritoneum: evidence by ussing-type chamber experiments

The mesothelium is part of the peritoneal water and ion transport barrier essential for peritoneal dialysis (PD) treatment and has a central role in the pathogenesis of peritoneal fibrosis and ultrafiltration failure observed in many PD patients. We investigated the effect of amiloride on the transmesothelial electrical resistance (RTM) of isolated parietal human peritoneum. Intact sheets were obtained from seven patients (three men, four women; mean age, 64 +/- 8 years). Fourteen peritoneal planar sheets were transferred to the laboratory in oxygenated Krebs-Ringer bicarbonate solution at 4 degrees C within 30 minutes after removal and mounted in an Ussing-type chamber. Amiloride (10(-3) mol/L) added apically (n = 8) caused a rapid rise of the RTM to 24.15 +/- 0.76 [OMEGA]H cm2 and a subsequent value persistence (p < 0.05); added basolaterally (n = 6), it increased the RTM to 22.66 +/- 0.59 [OMEGA]H cm2 within 1 minute, which persisted throughout the experiment. RTM was measured before and serially for 30 minutes after addition of amiloride. Control RTM was 20.29 +/- 0.86 [OMEGA]H cm2. These results indicate a rapid inhibitory effect of amiloride on the ionic permeability of parietal human peritoneum. The increase in the RTM observed after addition of amiloride clearly indicates the existence of amiloride-sensitive sodium channels on the human parietal peritoneal membrane, which may play some role in the ultrafiltration process and sodium removal during PD.

Multiple small bowel ruptures due to ischemic enteritis: A case report

A rare case of multiple small bowel ruptures due to ischemic enteritis (ISE) is reported. The patient was admitted to the hospital with acute abdominal pain followed by bloody diarrhoeas. Preoperative colonoscopic findings were similar to those presented in Crohn’s disease. Intraoperatively, ischemic lesions and multiple ruptures were localized at the jejunum and the proximal ileum. Histopathological examination of the resected bowel segment established the diagnosis of ISE. Although ISE is not common, concurred multiple ruptures of the small bowel is a rare but actual complication.

Gross calcification of the small bowel in a continuous ambulatory peritoneal dialysis patient with sclerosing peritonitis

We present here the case of a continuous ambulatory peritoneal dialysis (CAPD) patient who developed sclerosing calcifying peritonitis with gross macroscopic calcification of the small bowel, a rare and life-threatening complication of sclerosing peritonitis. A 40-year-old female had been on CAPD for 7 years. A peritoneal biopsy during an open cholecystectomy for cholelithiasis showed sclerosing peritonitis, but the patient refused to change dialysis modality. She remained free of symptoms for 3 years, but then was admitted with cloudy effluent, abdominal pain, and referred pain to the left shoulder. A white blood cell count showed 25,000 cells/microL, and a peritoneal cell count showed 1000 cells/microL. An abdominal computed tomography scan was nondiagnostic. The patient was started on intraperitoneal antibiotics, but 3 days later she was taken for surgery because of acute abdomen. Laparotomy revealed a tanned and thickened peritoneum and a small bowel with significant fibrosis and foci of calcification on the antimesenteric surface. Enterectomy and primary anastomosis was performed. Pathology revealed extensive mural fibrosis, calcium deposition, and localized inflammatory infiltration of the small bowel. The patient developed an anastomotic leak and, despite a second operation, died in the intensive care unit from septic shock. Although some authors report successful outcomes in similar cases by using surgery or other treatments (parenteral nutrition, immunosuppression), or both, we urgently recommend that, if sclerosing calcifying peritonitis is diagnosed, the patient be switched promptly to hemodialysis.

Inhibition by mercuric chloride of aquaporin-1 in the parietal sheep peritoneum: an electrophysiologic study

The peritoneal mesothelium is a barrier to ion transport in peritoneal dialysis. In this study, we used Ussing-chamber experiments to investigate the effect of HgCl2, an aquaporin-1 inhibitor, on the transmesothelial electrical resistance (RTM) of isolated sheep parietal peritoneum. Peritoneal samples from the diaphragm of adult sheep were isolated immediately after the death of the animal and were transferred within 30 minutes to the laboratory in a cooled Krebs-Ringer bicarbonate solution (4 degrees C, pH 7.5) bubbled with 95% O(2)/5% CO2. A planar sheet of the parietal peritoneum was mounted in an Ussing-type chamber and HgCl2 (10(-4) mol/L) was added apically or basolaterally. The RTM was measured before and serially after the addition of the HgCl2. The entire experimental apparatus was held at 37 degrees C, because active ion transport is temperature-dependent. The results presented are the mean +/- standard error of 12 experiments. The control RTM (that is, before the addition of HgCl) was 19.3 +/- 0.38 omega x cm2. Addition of HgCl2 apically induced a decrease in the RTM to 16.25 +/- 0.86 omega x cm2 within 1 minute. When added basolaterally, HgCl2 action was similar, with a rapid reduction in the RTM to 18.1 +/- 0.51 omega x cm2 (p < 0.05). A clear association between the RTM and the active transmesothelial ion transport was shown in previous studies. In the present study, rapid action of HgCl2 on the permeability ofthe parietal peritoneum was observed, resulting in a reduction in the RTM Taken together, these findings indicate that inhibition of aquaporin-1 alters the ionic permeability of the parietal peritoneal membrane.

Enhancement of the Transmesothelial Resistance of the Parietal Sheep Peritoneum by Epinephrine In Vitro: Ussing-type Chamber Experiments

The peritoneal mesothelium constitutes an ion transport barrier that is taken advantage of in peritoneal dialysis. The aim of this study was to investigate the effects of epinephrine on the electrical transmesothelial resistance (R(TM)) of the isolated parietal sheep peritoneum by means of Ussing-type chamber experiments. Intact parietal (diaphragmatic) peritoneal samples were obtained from adult sheep immediately after sacrifice and transferred within 0.5 h to the laboratory in a cooled Krebs-Ringer bicarbonate solution (4 degrees C, pH 7.5), bubbled with 95% O2-5% CO2. A parietal peritoneal planar sheet was mounted in a Ussing-type chamber. Epinephrine (10(-7) M) was added to the apical and the basolateral side. The R(TM) was measured before and serially after the addition of epinephrine for 30 min. As active ion transport is temperature-dependent, all measurements were performed at 37 degrees C. The results were calculated as means with standard errors (x +/- SE) of six independent experiments. The control R(TM) was 20.05 +/- 0.61 ohm x cm2. The addition of epinephrine to the basolateral side within 1 min induced an increase of R(TM) to 21.8 +/- 0.45 ohm x cm2, which decreased thereafter progressively to reach control values again after 15 min. A similar effect of epinephrine on the apical side was apparent with a rapid rise of R(TM) to 22.5 +/- 0.66 ohm x cm2 and a subsequent decrease (P < 0.05). A clear association between the R(TM) and active ion transport was established from previous studies. The results of our study indicate a rapid action of epinephrine on the parietal peritoneum permeability.

Influence of the sodium transport inhibition by amiloride on the transmesothelial resistance of isolated visceral sheep peritoneum

The peritoneal mesothelium is a barrier to ion transport in peritoneal dialysis. In the present study, we used Ussing chamber experiments to investigate the effect of amiloride on the transmesothelial electrical resistance (R(TM)) of isolated visceral sheep peritoneum. Peritoneal samples from the omentum of adult sheep were isolated directly after the death of the animals and were transferred to the laboratory within 30 minutes in a cooled Krebs-Ringer bicarbonate solution (4 degrees C, pH 7.5) bubbled with 95% O2/5% CO2. A visceral peritoneal planar sheet was mounted in an Ussing-type chamber and amiloride (10(-3) mol/L) was added apically and basolaterally. The R(TM) was measured before and serially for 30 minutes after the addition of amiloride. Because active ion transport is temperature dependent, the Ussing chambers were held at 37 degrees C. The results presented are the means + standard error of 12 experiments. The control R(TM) (before the addition of amiloride) was 21.86 +/- 0.46 omega x cm2. Basolateral addition of amiloride induced, within 1 minute, an increase in R(TM) to 27.26 +/- 0.39 omega x cm2, a level that persisted throughout the experiment. When amiloride was added apically, the results were similar with a rapid rise of R(TM) to 24.18 +/- 0.9 omega x cm2 and subsequent value persistence (p < 0.05). A clear association between R(TM) and active ion transport was shown in previous studies. The results of the present study indicate rapid action of amiloride on the permeability of the visceral peritoneum. The observed increase in the R(TM) indicates the existence of amiloride-sensitive sodium channels in the visceral peritoneal membrane. The clinical implications of these results should be further investigated.

Blunt diaphragmatic rupture

OBJECTIVE

To identify (1) predictors of outcome in blunt diaphragmatic rupture (BDR), and (2) factors contributing to diagnostic delay.

METHODS

We reviewed the charts and radiographs of 41 patients with BDR treated in our Hospital from 1988 to 1997. There were 35 male (85%) and six female, aged 17-71 (mean: 41) years. BDR was left-sided in 24 cases (58%), right-sided in 15 (36%) and bilateral in two (5%).

RESULTS

Two groups of patients can be identified: group A (n = 36, 88%) with acute BDR, and group B (n = 5, 12%) with post-traumatic diaphragmatic hernia (TDH). In group A, immediate diagnosis was made in 35 cases (97%), but only in 26 (72%) preoperatively. In one case, a right BDR was missed on initial evaluation but became apparent 2 weeks later. Associated injuries were present in 34 patients (94%) involving: spleen (n = 18), rib fractures (n = 17), liver (n = 14), lung (n = 11), bowel (n = 7), kidney (n = 5) and other fractures (n = 21). Injury Severity Score (ISS) ranged from 9 to 66 (mean: 31). BDR repair was accomplished through a laparotomy in 22 cases, thoracotomy in 10 and laparo-thoracotomy in four. The overall mortality rate was 16.6% (6/36). Both patients with bilateral BDR died. The patients who died were older than the survivors (mean age: 54 vs. 39 years, P<0.05), were more severely injured (mean ISS: 46 vs. 28, P<0.05) and were in shock (100 vs. 23%, P<0.05). In group B with TDH, diagnosis was delayed for 7-16 months after injury. Four patients had non-specific clinical signs and one strangulation of hollow viscera. One patient had undergone surgery during acute injury but BDR was overlooked. Location of TDH was on the left in three cases and on the right in two. Delay in BDR diagnosis was 12.5% (3/24) in patients with left-sided and 20% (3/15) in patients with right-sided lesions (P>0.1). Repair of TDH was achieved through thoracotomy in all cases. No mortality or major morbidity were encountered.

CONCLUSIONS

(1) Predictors of BDR mortality are: age, ISS and hemodynamic status of the patient. (2) Delay in diagnosis does not influence the outcome and is not influenced by the side of BDR location. (3) BDR can easily be missed in the absence of other indications for prompt surgery, where a thorough examination of both hemidiaphragms is mandatory. A high index of suspicion combined with repeated and selective radiologic evaluation is necessary for early diagnosis.