Oncological outcomes in oncoplastic breast surgery: a single institution analysis

Oncoplastic surgery is a well-acknowledged technique that combines conserving treatment in breast cancer with plastic surgery reconstruction. The aim of our analysis is to evaluate the safety of this surgical procedure in the setting of invasive primary breast cancer, and then compare breast oncoplastic surgery with the Veronesi quadrantectomy.We have analyzed 1541 patients who underwent breast surgery for primary breast tumor between October 2004 and May 2018 at Sant'Andrea University Hospital in Rome: 880 women experienced the breast oncoplastic approach, while 660 patients received conservative surgery alone. The median follow-up time was 14 years with a completeness of 70% (1067 pts vs 1554). The statistic comparison across these subpopulations suggested that there are no statistically significant results in term of Overall Survival, Disease Related Survival, Local recurrence or positive margins. Therefore oncoplastic surgery for primary invasive breast cancer represents a feasible procedure and an oncological safe surgical option.

Role of EGFR family receptors in proliferation of squamous carcinoma cells induced by wound healing fluids of head and neck cancer patients

BACKGROUND

Mounting evidence suggests that recurrence of resected head and neck squamous cell carcinomas (HNSCCs) is due to the outgrowth of unrecognized residual tumor cells as well as to the premalignant and/or precursor-field epithelial cells. We studied the impact of processes triggered by HNSCC surgery in stimulating both residual tumor cells [demonstrated to overexpress epidermal growth factor receptor (EGFR)], and premalignant cells surrounding the resected lesion.

PATIENTS AND METHODS

EGFR expression/activation by immunohistochemistry/biochemistry and gene status by FISH were investigated in 23 primary HNSCCs and surrounding tissues. The ability to induce cell proliferation of wound healing drainages collected from 12 relapsed and 11 not relapsed patients was evaluated by a colorimetric assay in squamous cell carcinoma cell lines A431 (carrying EGFR amplification) and CAL27 (carrying three EGFR copies) in the presence/absence of EGFR therapeutic inhibitors.

RESULTS

Primary tumors showed intermediate/high EGFR expression (91%), EGFR phosphorylation and EGFR-positive FISH (35%). Normal, metaplastic and dysplastic epithelium surrounding the resected tumor displayed EGFR overexpression. EGFR activation and gene amplification were observed in normal and dysplastic epithelium, respectively. Each tested wound healing drainage induced the cells to proliferate and the proliferation was significantly higher in relapsed compared with not relapsed HNSCC patients (P = 0.02 and P = 0.03). Anti-EGFR treatments inhibited the drainage-induced proliferation, with the highest inhibitory efficiency by cetuximab on A431 cells, while CAL27 cell growth was more efficiently inhibited by tyrosine kinase inhibitors.

CONCLUSIONS

Surgery could favor the proliferation of cells showing EGFR overexpression/activation/amplification such as residual tumor cells and/or precursor-field epithelial cells already present after surgery. Treatment with anti-EGFR reagents inhibits wound-induced stimulation, according to the EGFR family status.

[Laparoscopic conservative treatment of ovarian dermoid cysts]

Two methods for the laparoscopic dissection of dermoid ovarian cysts, less than 10 cm, in 55 fertile women, are compared. Water dissection was performed in 23 patients and bipolar scissors were used in 32 patients, creating a rhomb on the surface of the ovary, just to obtain a good traction for atraumatic dissection. The mean surgical time, complications and hospital stay have been compared. Operative laparoscopy is the technique of choice to remove most, if not all, ovarian dermoid cysts. It is suggested to use particular strategies in order to safely and easily dissect in toto the cysts.

[The use of Foley's catheter and suturing to control abdominal wall haemorrhage provoked by the trochar. Comparative study]

Lesions of the abdominal vessels are becoming more frequent owing to the increase in the number of laparoscopies carried out with trochars: they occur in fact in 2% of cases. A study has been carried out to compare the effectiveness of 2 methods for stopping haemorrhage: the use of a Foley catheter and suturing with a Reverdin needle. Abdominal haemorrhages take place as a result of lesions during introduction of accessory trochars in the superficial, circumflex and deep epigastric vessels. Six patients were treated with Foley's catheter while 13 were treated with Reverdin's needle under visual control, maintaining the same operative route, something that is not possible with the Foley catheter. Patients treated with suturing were discharged within 24 hours without irritation or pain.

[Value and significance of cystoscopy during laparoscopic hysterectomy]

The purpose of our study is to identify the ureteral and vesical lesions that may occur in the course of total laparoscopic hysterectomy using intraoperative cystoscopy. After the patient has been placed in dorsolithotomic position, we used a Hourcabie manipulator, a 10 mm umbilical trochar and two 5-mm suprapubics. Total hysterectomy is carried out and after closing the vagina 5 ml of stain in a physiological solution are injected into the vein to carry out cystoscopy. Analysis refers to the first 120 patients from 1998 to 1999 treated with laparoscopic hysterectomy. No material or vesical intraoperative lesions were found in any of the patients with the exception of a vesical lesion which was sutured during laparoscopy. Even with the cystoscopic finding normal, 2 fistulas were observed 20 and 25 days after the operation, so the negativity of the cystoscopy excludes certainly immediate complications but not late ones. Furthermore, not all surgeons carry out intraoperative cystoscopy, so the data available are scanty.

Does chronic pacing affect exercise capacity after Mustard operation for transposition of the great arteries?

Late survival after Mustard repair of transposition of the great arteries is generally good but is often characterized by progressive deterioration of ventricular function and by late postsurgical arrhythmias, thus imposing the need for permanent pacing. To evaluate how chronic pacing affects long-term exercise capacity, we compared two groups of these patients: group 1, comprising 12 patients, aged 9.0 +/- 2.6 years, without pacemaker; and group 2, comprising 18 patients, aged 9.3 +/- 2.0 years, with pacemaker. Patient evaluation included history, physical examination electrocardiograph, Holter monitoring, and echocardiography. Pacing modes were as follows: AAI (6 patients), AAIR (9 patients), VVI (2 patients), and VVIR (1 patient). At exercise test we evaluated exercise tolerance, maximum heart rate, blood pressure, oxygen consumption, and cardiac output at rest and at peak exercise. The two groups were comparable for all variables examinated. All pacemakers showed normal function. During the exercise, 11 of 12 patients in group 1 showed sinus rhythm, and in group 2, 11 patients showed sinus rhythm, 5 junctional rhythm, and 2 continuous pacing. There were no significant differences between groups. Chronically paced Mustard patients but with restoration of spontaneous rhythm during the exercise test do not show reduced exercise tolerance in comparison with nonpaced Mustard patients.

Cardiorespiratory functional assessment after pediatric heart transplantation

Limited data are available on the exercise capacity of young heart transplant recipients. The aim of this study was therefore to assess cardiorespiratory responses to exercise in this group of patients. Fourteen consecutive heart transplant recipients (six girls and eight boys, age-range 5-15 yr) and 14 healthy matched controls underwent a Bruce treadmill test to determine: duration of test; resting and maximum heart rates; maximum systolic blood pressure; peak oxygen consumption (VO2 peak); and cardiac output. Duration of test and heart rate increase were then compared with: time since transplantation, rejections per year, and immunosuppressive drugs received. The recipients also underwent the following lung function tests: forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1). When compared with healthy controls, transplant recipients had tachycardia at rest (126 +/- 3.7 beats/min; p < 0.001); significantly reduced tolerance (9.3 +/- 0.4 min; p < 0.001), a maximum heart rate of 169 +/- 5.4 beats/min (p < 0.05); a cardiac output of 5.65 +/- 0.6 L/min (p < 0.05); and a lower heart-rate increase from rest to peak exercise (p < 0.001) but a similar VO2 peak. The heart-rate increase correlated significantly with time post-transplant (r = 0.55; p < 0.05), number of rejection episodes per year (r = - 0.63; p < 0.05), and number of immunosuppressive drugs (r = - 0.60; p < 0.05). The recipients had normal FVC and FEV1 values. After surgery, few heart transplant recipients undertake physical activity, possibly owing to over-protective parents and teachers and to a lack of suitable supervised facilities. The authors stress the importance of a cardiorespiratory functional evaluation for assessment of health status and to encourage recipients, if possible, to undertake regular physical activity.

Clinical and cardiorespiratory assessment in children with Down syndrome without congenital heart disease

OBJECTIVE

To assess the clinical and functional status of a young Down syndrome (DS) population without congenital heart disease.

DESIGN

Prospective study of children with DS and control subjects.

SETTING

Bambino Gesù Children's Hospital, Rome, Italy.

PARTICIPANTS AND METHODS

Forty-two children with DS (mean +/- SD age, 9.8 +/- 3.6 years) underwent genetic, clinical, neuropsychological (IQ), and cardiorespiratory evaluation. Cardiorespiratory fitness was assessed with a treadmill test and a lung function test to determine forced vital capacity, first-second forced expiratory volume, and peak expiratory flow. Data were expressed as a percentage of the predicted values for control children. To assess cooperation during exercise testing, we devised a compliance scale assigning a score according to the subjects' ability to understand instructions, ability to walk and run as required, and need for vocal encouragement.

RESULTS

Eighteen (43%) of 42 children with DS were obese, 10 (24%) were short, and 17 (40%) had microcephaly. On the Leiter International Performance Scale, 2 of 35 subjects had a normal IQ score (80-120); all others had low IQ scores (79 to <40). Five subjects did not undergo cardiorespiratory assessment. Eighteen of 37 subjects completed lung function tests: the results for 10 were unremarkable, and results from 8 revealed reduced forced vital capacity because of poor compliance. The subjects tested had low exercise tolerance (mean +/- SD tolerance percentage, 61% +/- 12%), mild tachycardia (maximal heart rate, 91% +/- 4%), and a mild hypertensive response (maximal blood pressure, 89% +/- 8%). Compliance scores correlated significantly with exercise time and age but not with IQ.

CONCLUSIONS

Clinical and cardiorespiratory assessment is feasible in subjects with DS without congenital heart disease and should be useful in gauging their fitness level for safe physical activity.

Exercise testing as a rehabilitative/training tool

Exercise testing is an exceedingly useful noninvasive method for assessing cardiovascular function not only at rest but also during programmed, supervised physical exercise. Exercise testing has been intensively studied to delineate the cardiovascular response in various disorders [3-5, 15, 19, 22, 23, 26, 32]. Exercise testing as a tool for rehabilitation and for training to perform physical activity is discussed here.

Exercise tolerance and blood pressure response to exercise testing in children and adolescents after renal transplantation

The aim of the study was to assess exercise tolerance and blood pressure (BP) response to treadmill exercise in children after renal transplantation. Forty-five children were selected (29 males and 16 females) whose mean age was 14.3 +/- 4.2 years. All children had Hb >/= 10 g/dl and creatinine clearance >/=40 ml/min/1.73 m2. They were at least 6 months posttransplantation and were on triple immunosuppressive therapy. Twenty-seven were also on various antihypertensive medications. Each underwent clinical examination and measurement of BP, both at rest and during exercise testing on treadmill. The test was stopped on muscular fatigue or exhaustion. The patients were divided into two groups: those off (A) or on (B) antihypertensive therapy. When compared to a population of healthy children the patients had reduced exercise tolerance (10.1 +/- 2.1 vs 15.1 +/- 1.7 min, p < 0.001) (67 +/- 16%), increased heart rate (174 +/- 19 vs 161 +/- 19 beats/min, p < 0.001) (109 +/- 15%), and increased maximum systolic BP (150 +/- 26 vs 134 +/- 13 mmHg, p < 0. 001) (113 +/- 19%) at comparable workloads. Within the two patient groups, significant differences were observed during exercise testing for maximum heart rate, which was lower in group B (p = 0.03), and maximum systolic BP, which was higher in group A (p = 0.04). Our study confirms that children and adolescents on immunosuppressive therapy after renal transplantation have a hypertensive response during exercise, probably related to medication-induced peripheral vascular tone.

The natural history and the effects of gabapentin in amyotrophic lateral sclerosis

Glutamate excitotoxicity seems to play an important role in the aetiopathogenesis and progression of Amyotrophic Lateral Sclerosis (ALS). Gabapentin is a modulator of the glutamatergic system and has been shown to prolong survival in the transgenic model of familial ALS. It has also been demonstrated to slow the decline of arm strength in human sporadic cases. The aim of our study was to assess the effects of different dosages and duration of treatment of gabapentin on the natural history and survival of ALS patients. A total of 110 patients affected by definite ALS entered the study. After a 6-12 month period of observation, patients were randomly assigned to receive oral gabapentin 500 mg/day (Group A) or 1000 mg/day (Group B) for 6 months. In addition a group of patients received gabapentin 500 mg/day for 6 months and 1000 mg/day for a further 6 months (Group C). A group of 121 patients referred to our Institute, who received only symptomatic treatment, was considered as the control group (Group D). Each patient was seen at entry and every 3 months. All average slopes were negative but the comparison of all slopes showed a trend toward a slower rate of decline of muscle strength loss in all treated groups of patients compared with the control group. The differences were statistically significant. Analysis between the pretreatment and treatment period showed a statistically significant decrease of the decline of muscle strength and Norris score during the treatment period. Survival analysis showed a significantly longer survival in treated patients of Groups B and C. Our study suggests that gabapentin may be an effective drug for ALS; hence a controlled trial involving a sufficient large number of patients is warranted.

Hypertension in young patients after renal transplantation: ambulatory blood pressure monitoring versus casual blood pressure

The results of ambulatory blood pressure monitoring (ABPM) in children after kidney transplant were analyzed to ascertain any alteration in circadian BP profile, degree of hypertension, and efficacy of therapy. The data were also compared with casual BP data and left ventricular mass index (LVMI). We have examined 30 patients (17 male, 13 female), mean age 16.1+/-3.6 years after kidney transplant. All patients were receiving triple immune-suppressive therapy and 20 of them were also taking antihypertensive therapy. They underwent clinical examination with measurement of BP at rest, echocardiogram mono-2D, and ABPM. The following ABPM parameters were recorded: systolic (S) and diastolic (D) BP at rest; mean 24-h SBP and DBP; mean daytime SBP and DBP; mean nighttime SBP and DBP; nocturnal fall in SBP and DBP; and mean daytime and nighttime heart rate (HR). The patients were divided in two groups. Group A consisted of 20 patients taking antihypertensive treatment; group B consisted of 10 patients not taking antihypertensive treatment. Casual and ABPM data for the two groups were compared using the Student t test for unpaired data. Blood pressure at rest and LVMI were not statistically different between the two patient groups. The ABPM data showed statistical differences between the two groups for mean 24-h SBP and DBP, daytime and nighttime SBP, nighttime DBP, fall in nocturnal DBP, and nighttime HR. Mean 24-h SBP and DBP, mean daytime SBP and DBP, and mean nighttime SBP and DBP were significantly correlated to LVMI (respectively, P = .009, P = .005, P = .008, P = .007, P = .05, and P = .01). Twenty-four-hour ABPM was more useful in the diagnosis and management of hypertension than was casual BP at rest.

Exercise tolerance and behavior of blood pressure in children and adolescents after renal transplant

OBJECTIVE

The purpose of the study was to evaluate the exercise tolerance and the behaviour of blood pressure during a maximal exercise testing on treadmill for a group of patients with renal transplant carried out at least 6 months earlier. EXPERIMENTAL DESIGN, SETTING AND PATIENTS: In a retrospective study, nineteen patients were examined in our laboratory: 13 boys and 6 girls, mean age 15.8 years (range 10.5-22).

INTERVENTIONS

All patients were given a clinical examination, an ECG at rest, a maximal exercise testing on treadmill (Bruce protocol), a mono-2D echo, a lung function test and 24-hour Holter monitoring. The results of the exercise test were compared with those of two control groups of same age and body surface area.

RESULTS

The clinical examination of their cardiovascular apparatus gave normal results. The echo revealed anatomical and heart function anomalies related to the original disease. Exercise testing on treadmill showed a reduction in exercise tolerance (p < 0.001) and the maximal heart rate showed a statistically significant difference (p < 0.001) in comparison to control groups. Maximal systolic blood pressure was higher than in patients with same body surface area (p < 0.001) and higher than in peers (p = 0.133).

CONCLUSIONS

In view of this hypertensive response, strenuous physical activity should be undertaken with caution and indeed submaximal aerobic activity is more suitable for this population of patients.

[Cardiac rehabilitation in children. Interdisciplinary approach]

The concept of rehabilitation has been defined by the authors as a supervised process of progressive exercise training to improve aerobic fitness. Cardiac rehabilitation in children should be dedicated to patients with repaired complex congenital heart diseases who have residual functional and psychological problems. The basic objectives for rehabilitation are defined: to improve exercise efficiency, aerobic capacity and quality of life, to reduce the incidence of sudden death, to enable young patients to take part safely and effectively in athletics. The guidelines for organising a cardiac rehabilitation programme are specified. First of all the need of protected environments, functional evaluation before starting the programme, the description of the rehabilitation session and staff needed. Equally important is the psychosocial aspect. It is difficult to quantify, in a scientific manner, the effectiveness of psychosocial intervention, but it helps the children to integrate into social life thus enhancing their quality of life. The results of a census of 110 world-wide centres offering regular cardiac rehabilitation programmes are presented. Italy currently has only two centres suitable for pediatric cardiac rehabilitation: they treat a small number of patients. Personal experience, with 20 patients, agrees with that of Galioto, about an increase in exercise capacity of these patients after rehabilitation programme, with an increased cardiac output at rest and at peak of exercise, an increased O2 uptake and an increased duration of exercise testing. The usefulness of cardiac rehabilitation programmes, the need of interdisciplinary approach and increasing the case series are stressed.

[Functional evaluation by treadmill in children and adolescent following correction of Tetralogy of Fallot]

AIM OF THE STUDY

The Authors have examined 22 children (16m and 6f), mean age 9.64 +/- 2.63 years, range 5-15, after total correction for Tetralogy of Fallot, to evaluate the response of their cardiovascular apparatus during an exercise testing on treadmill (Bruce protocol).

METHODS

Parameters examined: exercise duration, maximal heart rate (HR), maximal systolic blood pressure (max BP), non invasive cardiac output at rest and at the peak of exercise (CO), arterial oxygen saturation; lung function test at rest, echocardiogram and 24 hours Holter monitoring.

CONTROL GROUP

22 healthy peers, same gender, height and weight, not practising competitive sports.

RESULTS

The exercise duration was significantly lower in the first group (77.8 +/- 11.8%; 86.5 +/- 8.2%; P = 0.006). Also max HR and max BP were significantly lower (max HR: 162 +/- 12 b/m'; 187 +/- 8 b/m'; P = 0.000), (max BP: 119 +/- 9 mm Hg; 126 +/- 12 mm Hg; P = 0.042). There were no differences for CO at rest (3.70 +/- 1.09 l/m'; 3.95 +/- 1.07 l/m'). In the first group, CO at peak of exercise was lower but not significantly (6.51 +/- 2.56 l/m'; 7.95 +/- 2.77 l/m'; NS).

CONCLUSIONS

These results make more complete the not invasive functional evaluation for a better follow-up of these patients and a better choice for their physical activity.

[Anesthesia in experimental single-lung transplantation: hemodynamic and respiratory changes during prostaglandin E1 and nitroglycerin infusion]

INTRODUCTION

The haemodynamic and oxyforetic modifications induced by continuous infusion (c.i.) of Prostaglandin E1 (PGE1) and Nitroglycerin (NG) during experimental lung transplantation have been studied.

METHODS

Twenty lung transplants have been performed on pigs (Landrace). Haemodynamic monitoring consisted of ECG, femoral cannulation for arterial pressure and Swan Ganz catheter. Continuous infusion of drugs started during pneumonectomy. Data have been collected in phase 1: after the induction of anaesthesia; in phase 2: 30 min after the start of pulmonary vasodilation in one lung ventilation with left pulmonary artery clamped; in phase 3: 30 min after lung revascularization; in phase 4: at the end of the surgery. The animals have been divided in two groups. Group A consisted of 10 cases treated with 50 ng/kg/min in phase 2 and 25 ng/kg/min in phase 3 and 4 of PGE1; group B consisted of 10 cases treated with 1 ncg/kg/min in phase 2 and 0.5 ncg/kg/min in phase 3 and 4 of NG.

RESULTS

In phase 2 and 4 PA, RVSWI, PRVI increased in group B more than in group A (p < 0.05); in phase 3 PA, PAWP increased in group B more than in group A (p < 0.05).

DISCUSSION

In our experience PGE1 has shown to be a stronger pulmonary vasodilator than NG. PGE1 can be considered the drug of choice for pulmonary vasodilation in experimental single lung transplantation, even if more investigations are needed for reaching the real goal of this procedure.

[Hemodynamic and respiratory aspects in orthotopic liver transplantation]

Intraoperative hemodynamic and respiratory data from one-year experience of orthotopic liver transplantation with veno-venous bypass (10 cases) were collected. Seven different phases of OLT was submitted to one way analysis of variance. Variability is due to degree and duration of liver disease. Basal conditions include high cardiac output with low SVRI, elevated Qs/Qt. and low oxygen consumption. Anhepatic phase shows a lower cardiac index due to reduction in ventricular performance too. The functioning graft raises body oxygen consumption above baseline. Last phases show diminution of MAP and LVSWI and a normal Qs/Qt.

Cerebral hemispheric "counter-steal" phenomenon during hyperventilation in cerebrovascular diseases

Use of hyperventilation (HV) was recently suggested for the treatment of acute cerebrovascular insufficiency. There is indeed no general agreement on the effectiveness of hyperventilation even though clinical and experimental findings could support its value in clinical use.

During carotid surgery, hyperventilation was used in order to attenuate cerebral ischemia effects during carotid clamping, and a counter-steal phenomenon affecting a whole cerebral hemisphere was demonstrated.

This suggests the role that hyperventilation may play in the treatment of cerebral ischemia.