Ovarian Causes of Pseudomyxoma Peritonei (PMP)-A Literature Review

BACKGROUND

Pseudomyxoma peritonei (PMP) is a rare, progressive, slowly growing, inadequately understood neoplasm with a 5-year progression-free survival rate of as low as 48%. It is characterized by varying degrees of malignancy and the production of mucinous and gelatinous structures. Typically, the development of pseudomyxoma peritonei is associated with the rupture of appendiceal mucinous tumors and other gastrointestinal or ovarian mucinous tumors. The goal of our literature review was to identify various aspects that characterize the ovarian causes of pseudomyxoma peritonei.

MATERIALS AND METHODS

The authors performed an extensive literature search between 1 February 2024 and 2 March 2024 on the following databases: Pubmed, Scopus, Oxford Journals, and Reaxys, and the findings were summarized into seven main clinical and paraclinical situations.

RESULTS

According to our research, the main instances in which pseudomyxoma peritonei can be triggered by an ovarian cause are the following: (1) mucinous cystadenoma; (2) mucinous ovarian cancer; (3) colon cancer with ovarian metastasis; (4) malignant transformation of an ovarian primary mature cystic teratoma; (5) appendiceal mucocele with peritoneal dissemination mimicking an ovarian tumor with peritoneal carcinomatosis; (6) mucinous borderline tumor developing inside an ovarian teratoma; and (7) the association between a mucinous bilateral ovarian cancer and a colonic tumor.

CONCLUSIONS

In our study, we aimed to provide a comprehensive overview of the ovarian causes of pseudomyxoma peritonei, including its epidemiology, imagery characteristics, symptoms, current treatment, and promising future therapies, in the hopes of finding feasible solutions, as a lack of understanding of this mucus-secreting malignant disease increases the risk of delayed diagnosis or uncontrolled deterioration.

Tips and Tricks for a Successful Literature Review as Part of Medical Career Development

The literature review is a direct consequence of the increased volume of scientific information, becoming a necessity not only for the medical field. Such material, properly done, is of great use to any professional who wishes to keep abreast of the latest knowledge and concepts. The proposed goal is to help and guide resident doctors, doctoral students, and young researchers in understanding the concepts that are the basis of conducting a literature review and acquiring the generally accepted methodology for conducting it. The selection of information sources, accessing databases, the concept of peer-review, indexing and the impact factor are clearly presented as elements that cannot be neglected in the valorisation of scientific information sources. The structure of a literature review must consider the generally accepted format for such an article, with each chapter having its own importance. Depending on the quality and heterogeneity of the results obtained after analysing the collected data, the review can be structured narratively or systematically, the homogeneity of the results allowing the application of statistical study methods (meta-analysis). Although it seems difficult, conducting a literature review is easier and faster than developing an original study based on experimental or clinical scientific research. The literature review can be carried out in comfortable conditions, online, regardless of location and is a welcome support in the development of the professional and scientific career.

Feasibility of Sentinel Lymph Node Biopsy in Breast Cancer Patients with Axillary Conversion after Neoadjuvant Chemotherapy-A Single-Tertiary Centre Experience and Review of the Literature

(1) Introduction: Sentinel lymph node biopsy (SLNB) is widely used in breast cancer patients who undergo neoadjuvant chemotherapy (NAC), replacing axillary lymph node dissection. While commonly accepted for cN0 patients, its role in cN1/2 patients remains controversial. Our study aims to investigate the role of SLNB in BC patients who underwent prior NAC and compare our results to those of other studies presented in the literature. (2) Materials and methods: Our retrospective study included 102 breast cancer patients who received NAC before 99mTc-albumin Nanocolloid SLN mapping and SLNB was performed, completed or not with axillary dissection. A review based on the PRISMA statement was also carried out, encompassing 20 studies. (3) Results: The lymphoscintigraphy performed after the administration of NAC presented an identification rate (IR) of 93.13%. IR for SLNB was 94.11%, with a false-negative rate (FNR) of 7.4%. After a median follow-up of 31.3 months, we obtained a distant disease-free survival rate of 98%. The results obtained by other groups were similar to those of our study, presenting IR in the range 80.8-96.8%, with FNR varying from 0 to 22%. (4) Conclusions: on conclusion, SLNB can accurately determine the lymph node status, with an acceptable FNR and maintain its expected prognostic role with low recurrence rates, and our results are comparable to those obtained by other studies.

Quantitative vs. Qualitative SPECT-CT Diagnostic Accuracy in Bone Lesion Evaluation-A Review of the Literature

(1) Background: Considering the importance that quantitative molecular imaging has gained and the need for objective and reproducible image interpretation, the aim of the present review is to emphasize the benefits of performing a quantitative interpretation of single photon emission computed tomography-computed tomography (SPECT-CT) studies compared to qualitative interpretation methods in bone lesion evaluations while suggesting new directions for research on this topic. (2) Methods: By conducting comprehensive literature research, we performed an analysis of published data regarding the use of quantitative and qualitative SPECT-CT in the evaluation of bone metastases. (3) Results: Several studies have evaluated the diagnostic accuracy of quantitative and qualitative SPECT-CT in differentiating between benign and metastatic bone lesions. We collected the sensitivity and specificity for both quantitative and qualitative SPECT-CT; their values ranged between 74-92% and 81-93% for quantitative bone SPECT-CT and between 60-100% and 41-100% for qualitative bone SPECT-CT. (4) Conclusions: Both qualitative and quantitative SPECT-CT present an increased potential for better differentiating between benign and metastatic bone lesions, with the latter offering additional objective information, thus increasing diagnostic accuracy and enabling the possibility of performing treatment response evaluation through accurate measurements.

Portrait of the Inflammatory Response to Radioiodine Therapy in Female Patients with Differentiated Thyroid Cancer with/without Type 2 Diabetes Mellitus

No clinical studies have investigated the effect of radioiodine (131I)-targeted therapy on the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) as inflammatory response markers in patients with differentiated thyroid cancer (DTC) associated with type 2 diabetes mellitus (T2DM) and obesity. This study aimed to assess the relationship between blood radioactivity, body mass index (BMI), and peripheral blood cells three days after 131I intake in 56 female patients without T2DM (DTC/-T2DM) vs. 24 female patients with T2DM (DTC/+T2DM). Blood radioactivity, measured three days after 131I intake, was significantly lower in the DTC/+T2DM than in the DTC/-T2DM patients (0.7 mCi vs. 1.5 mCi, p < 0.001). The relationship between blood radioactivity and BMI (r = 0.83, p < 0.001), blood radioactivity and NLR (r = 0.53, p = 0.008), and BMI and NLR (r = 0.58, p = 0.003) indicates a possible connection between the bloodstream 131I uptake and T2DM-specific chronic inflammation. In patients without T2DM, 131I therapy has immunosuppressive effects, leading to increased NLR (19.6%, p = 0.009) and PLR (39.1%, p = 0.002). On the contrary, in the chronic inflammation context of T2DM, 131I therapy amplifies immune metabolism, leading to a drop in NLR (10%, p = 0.032) and PLR (13.4%, p = 0.021). Our results show that, in DTC/+T2DM, the bidirectional crosstalk between neutrophils and obesity may limit 131I uptake in the bloodstream. Considering the immune response to 131I therapy, the two groups of patients can be seen as a synchronous portrait of two sides. The explanation could lie in the different radiosensitivity of T and B lymphocytes, with T lymphocytes being predominant in patients with DTC/-T2DM and, most likely, B lymphocytes being predominant in T2DM.

Quantitative SPECT/CT Parameters in the Assessment of Transthyretin Cardiac Amyloidosis-A New Dimension of Molecular Imaging

AIMS

Cardiac transthyretin amyloidosis (ATTR) represents the accumulation of misfolded transthyretin in the heart interstitium. Planar scintigraphy with bone-seeking tracers has long been established as one of the three main steps in the non-invasive diagnosis of ATTR, but lately, single-photon emission computed tomography (SPECT) has gained wide recognition for its abilities to exclude false positive results and offer a possibility for amyloid burden quantitation. We performed a systematic review of the existing literature to provide an overview of the available SPECT-based parameters and their diagnostic performances in the assessment of cardiac ATTR. Methods and Methods: Among the 43 papers initially identified, 27 articles were screened for eligibility and 10 met the inclusion criteria. We summarised the available literature based on radiotracer, SPECT acquisition protocol, analysed parameters and their correlation to planar semi-quantitative indices.

RESULTS

Ten articles provided accurate details about SPECT-derived parameters in cardiac ATTR and their diagnostic potential. Five studies performed phantom studies for accurate calibration of the gamma cameras. All papers described good correlation of quantitative parameters to the Perugini grading system.

CONCLUSIONS

Despite little published literature on quantitative SPECT in the assessment of cardiac ATTR, this method offers good prospects in the appraisal of cardiac amyloid burden and treatment monitoring.

Therapies beyond Physiological Barriers and Drug Resistance: A Pilot Study and Review of the Literature Investigating If Intrathecal Trastuzumab and New Treatment Options Can Improve Oncologic Outcomes in Leptomeningeal Metastases from HER2-Positive Breast Cancer

Leptomeningeal metastases (LM) are a rare but rapidly fatal complication defined by the spread of tumor cells within the leptomeninges and the subarachnoid space, found in approximately 10% of patients with HER2-positive breast cancers. This pilot study evaluated the efficacy of local treatment with intrathecal Trastuzumab (IT) added to systemic treatment. The oncologic outcome of 14 patients with HER2-positive LM is reported. Seven received IT, and seven received standard of care (SOC). The mean number of IT cycles administered was 12.14 ± 4.00. The response rate to CNS after IT treatment + SOC was 71.4%, and three patients (42.8%) obtained durable responses lasting more than 12 months. The median progression-free survival (mPFS) after LM diagnosis was six months, and the median overall survival (mOS) was ten months. The mean values of the PFS in favor of IT therapy (10.6 mo vs. 6.6 mo) and OS (13.7 vs. 9.3 mo) suggest a non-negligible investigation direction in the sense of exploiting intrathecal administration as a possible treatment modality in these patients. Adverse events reported were local pain related to intrathecal administration and one case of arachnoiditis, hematoma, and CSF fistulae. Intrathecal administration of Trastuzumab, alongside systemic treatment and radiotherapy, might improve oncologic outcomes in LM HER2-positive breast cancer with manageable toxicity.

Salvage Surgery for Small-Cell Lung Cancer-A Literature Review

(1) Background: Salvation surgery for small-cell lung cancer (SCLC) is exceptionally performed, and only a few cases are published. (2) Methods: There are 6 publications that present 17 cases of salvation surgery for SCLC-the salvation surgery was performed in the context of modern clearly established protocols for SCLC and after including SCLC in the TNM (tumor, node, metastasis) staging in 2010. (3) Results: After a median follow-up of 29 months, the estimated overall survival (OS) was 86 months. The median estimated 2-year survival was 92%, and the median estimated 5-year survival was 66%. (4) Conclusion: Salvage surgery for SCLC is a relatively new and extremely uncommon concept and represents an alternative to second-line chemotherapy. It is valuable because it may offer a reasonable treatment for selected patients, good local control, and a favorable survival outcome.

Analysis of Efficacy-To-Safety Ratio of Angiogenesis-Inhibitors Based Therapies in Ovarian Cancer: A Systematic Review and Meta-Analysis

(1) Background: Among new anti-angiogenesis agents being developed and ever-changing guidelines indications, the question of the benefits/safety ratio remains unclear. (2) Methods: We performed a systematic review combined with a meta-analysis of 23 randomized controlled trials (12,081 patients), evaluating overall survival (OS), progression free survival (PFS) and toxicity (grade ≥ 3 toxic effects, type, and number of all adverse effects. (3) Results: The analysis showed improvement of pooled-PFS (HR, 0.71; 95% CI, 0.64-0.78; I² = 77%; p < 0.00001) in first-line (HR, 0.85; 95% CI, 0.78-0.93; p = 0.0003) or recurrent cancer (HR, 0.62; 95% CI, 0.56-0.70; p < 0.00001) and regardless of the type of anti-angiogenesis drug used (Vascular endothelial growth factor (VEGF) inhibitors, VEGF-receptors (VEGF-R) inhibitors or angiopoietin inhibitors). Improved OS was also observed (HR, 0.95; 95% CI, 0.90-0.99; p = 0.03). OS benefits were only observed in recurrent neoplasms, both platinum-sensitive and platinum-resistant neoplasms. Grade ≥ 3 adverse effects were increased across all trials. Anti-angiogenetic therapy increased the risk of hypertension, infection, thromboembolic/hemorrhagic events, and gastro-intestinal perforations but not the risk of wound-related issues, anemia or posterior leukoencephalopathy syndrome. (4) Conclusions: Although angiogenesis inhibitors improve PFS, there are little-to-no OS benefits. Given the high risk of severe adverse reactions, a careful selection of patients is required for obtaining the best results possible.

Validation of a New Prognostic Score in Patients with Ovarian Adenocarcinoma

Background and Objectives: This study aimed to assess the impact of clinical prognostic factors and propose a prognostic score that aids the clinician's decision in estimating the risk for patients in clinical practice. Materials and Methods: The study included 195 patients diagnosed with ovarian adenocarcinoma. The therapeutic strategy involved multidisciplinary decisions: surgery followed by adjuvant chemotherapy (80%), neoadjuvant chemotherapy followed by surgery (16.4%), and only chemotherapy in selected cases (3.6%). Results: After a median follow-up of 68 months, in terms of progression-free survival (PFS) and overall survival (OS), Eastern Cooperative Oncology Group (ECOG) performance status of 1 and 2 vs. 0 (hazard ratio-HR = 2.71, 95% confidence interval-CI, 1.96-3.73, p < 0.001 for PFS and HR = 3.19, 95%CI, 2.20-4.64, p < 0.001 for OS), menopausal vs. premenopausal status (HR = 2.02, 95%CI, 1.35-3,0 p < 0.001 and HR = 2.25, 95%CI = 1.41-3.59, p < 0.001), ascites (HR = 1.95, 95%CI 1.35-2.80, p = 0.03, HR = 2.31, 95%CI = 1.52-3.5, p < 0.007), residual disease (HR = 5.12, 95%CI 3.43-7.65, p < 0.0001 and HR = 4.07, 95%CI = 2.59-6.39, p < 0.0001), and thrombocytosis (HR = 2.48 95%CI = 1.72-3.58, p < 0.0001, HR = 3.33, 95%CI = 2.16-5.13, p < 0.0001) were associated with a poor prognosis. An original prognostic score including these characteristics was validated using receiver operating characteristic (ROC) curves (area under the curve-AUC = 0.799 for PFS and AUC = 0.726 for OS, p < 0.001). The median PFS for patients with none, one, two, three, or four (or more) prognostic factors was not reached, 70, 36, 20, and 12 months, respectively. The corresponding median overall survival (OS) was not reached, 108, 77, 60, and 34 months, respectively. Conclusions: Several negative prognostic factors were identified: ECOG performance status ≥ 1, the presence of ascites and residual disease after surgery, thrombocytosis, and menopausal status. These led to the development of an original prognostic score that can be helpful in clinical practice.

Quantitative Assessment of Treatment Response in Metastatic Breast Cancer Patients by SPECT-CT Bone Imaging-Getting Closer to PET-CT

BACKGROUND

Cancer represents the major cause of death mainly through its ability to spread to other organs, highlighting the importance of metastatic disease diagnosis and accurate follow up for treatment management purposes. Although until recently the main method for imaging interpretation was represented by qualitative methods, quantitative analysis of SPECT-CT data represents a viable, objective option.

METHODS

Seventy-five breast cancer patients presenting metastatic bone disease underwent at least two Bone SPECT-CT studies using [^99mTc]-HDP between November 2019 to October 2022.

RESULTS

Our findings show a good positive relationship between the qualitative methods of imaging interpretation and quantitative analysis, with a correlation coefficient of 0.608 between qualitative whole body scintigraphy and quantitative SPECT-CT, and a correlation coefficient of 0.711 between the qualitative and quantitative interpretation of SPECT-CT data; nevertheless, there is a need for accurate, objective and reproducible methods for imaging interpretation, especially for research purposes.

CONCLUSIONS

Quantitative evaluation of the SPECT-CT data has the potential to be the first choice of imaging interpretation for patient follow up and treatment response evaluation, especially for research purposes, because of its objectivity and expression of uptake changes in absolute units.

Evaluating Cardiotoxicity in Breast Cancer Patients Treated with HER2 Inhibitors: Could a Combination of Radionuclide Ventriculography and Cardiac Biomarkers Predict the Cardiac Impact?

(1) Background: The aim of our study was to determine whether monitoring cardiac function through RNV and cardiac biomarkers could predict the cardiac impact of combined therapy with trastuzumab, pertuzumab and docetaxel, which are regularly used nowadays to treat HER2-positive breast cancer. (2) Methods: This prospective monocentric study included 22 patients, diagnosed with HER2-positive breast cancer, who had their LVEFs and cardiac biomarkers evaluated both at the beginning of their treatment and after 6 months. Among all of the enrolled patients, two blood specimens were collected to assess circulating cardiac biomarkers. RNV was performed in each patient after "in vivo" radiolabeling of the erythrocytes. The obtained results were then statistically correlated. (3) Results: The average LVEF decrease between the two time points was approximately 4%. Of the five biomarkers we considered in this paper, only NT-proBNP correlated with the LVEF values obtained both in the baseline study and after 6 months of follow-up (r = -0.615 for T0 and r = -0.751 for T1, respectively). ST2/IL-33R proved statistically significant at the T1 time point (r = -0.547). (4) Conclusions: A combination of LVEF, NT-proBNP and ST2/IL-33R assessment may be useful for early detection of cardiac impairment in breast cancer patients treated with trastuzumab, pertuzumab and docetaxel.

Understanding COVID Vaccination and Its Implication in Cancer Patients’ Imaging of Lymph Nodes by PET-CT

(1) Background: The appearance of enlarged lymph nodes on imaging adds another layer of complexity to the differential diagnosis of disease progression versus immune response to COVID-19 vaccines. Our aim was to find an optimal timing between the vaccination and the PET-CT scan. (2) Methods: 25 cancer patients with ¹⁸F-FDG PET-CT evaluations and a history of COVID-19 vaccination between September 2021 and December 2021 were retrospectively analyzed to characterize the lymph nodes related to the time interval from COVID vaccination. (3) Results: All patients presented one or more adenopathies localized in the ipsilateral axilla (96%), ipsilateral cervical area (20%), ipsilateral retropectoral (20%) and pulmonary hilum (8%). The median value of SUVmax was 3.5 ± 0.5. There was a significant indirect correlation between SUVmax and the time passed between the vaccination and the PET CT (Pearson Correlation r = −0.54, p = 0.005). There was no significant difference (p = 0.19) in the SUVmax value in patients receiving Moderna mRNA-1273 vaccine vs. BNT162b2 mRNA Pfizer vaccine. (4) Conclusions: Lymph node enlargement is commonly seen in patients post-vaccination for COVID-19 and must be differentiated from disease progression. The data from our study strongly suggests that the minimum interval of time between an mRNA vaccine and a PET-CT should be more than six weeks.

The New Radiolabeled Peptide 99mTcEDDA/HYNIC-TOC: Is It a Feasible Choice for Diagnosing Gastroenteropancreatic NETs?

(1) Background: The aim of our study is to reveal the advantages and limitations of the use of 99mTcEDDA/HYNIC-TOC (Tektrotyd®, Polatom) in the diagnosis of gastroenteropancreatic neuroendocrine tumors and to compare our results with the values obtained for 111In-pentetreotide and 68Ga-DOTA-peptides, routinely used in medical practice. (2) Methods: This retrospective monocentric study included 173 patients with gastroenteropancreatic neuroendocrine tumors who underwent 99mTcEDDA/HYNIC-TOC scans as part of their clinical management. The examination protocol included a whole-body scan acquired 2 h after the radiotracer's administration, with the SPECT/CT performed 4 h post-injection. Physiological and abnormal uptake were established by two experienced physicians and, based on the obtained results, sensitivity, specificity, accuracy, positive predictive value and negative predictive value were calculated. (3) Results: Our method presented a sensitivity of 90.5%, a specificity of 71.9%, and an accuracy of 84.3%, with a positive predictive value of 86.7% and a negative predictive value of 78.8%. (4) Conclusions: 99mTc-EDDA/HYNIC-TOC, a receptor-based radiopharmaceutical, could represent a competitor for 68Ga-labeled peptides in the diagnosis and management of patients with gastroenteropancreatic neuroendocrine tumors. Our results show a lower sensitivity (90.5%) than 68Ga-DOTA-peptides, but with great specificity, accuracy, positive, and negative predictive values.

Radiomics Analysis of [18F]FDG PET/CT Thyroid Incidentalomas: How Can It Improve Patients’ Clinical Management? A Systematic Review from the Literature

Background: We performed a systematic review of the literature to provide an overview of the application of PET-based radiomics of [18F]FDG-avid thyroid incidentalomas and to discuss the additional value of PET volumetric parameters and radiomic features over clinical data. Methods: The most relevant databases were explored using an algorithm constructed based on a combination of terms related to our subject and English-language articles published until October 2021 were considered. Among the 247 identified articles, 19 studies were screened for eligibility and 11 met the criteria, with 4 studies including radiomics analyses. Results: We summarized the available literature based on a study of PET volumetric parameters and radiomics. Ten articles provided accurate details about volumetric parameters and their prospective value in tumour assessment. We included the data provided by these articles in a sub-analysis, but could not obtain statistically relevant results. Four publications analyzed the diagnostic potential of radiomics and the possibility of creating precise predictive models, their corresponding quality score being assessed. Conclusions: The use of PET volumetric parameters and radiomics analysis in patients with [18F]FDG-avid thyroid incidentalomas outlines a great prospect in diagnosis and stratification of patients with malignant nodules and may represent a way of limiting the need for unnecessary invasive procedures; however, further studies need to be performed for a standardization of the method.

Maternal HPV Infection: Effects on Pregnancy Outcome

The human papilloma virus (HPV) infection, caused by a ubiquitous virus typically transmitted through the direct contact of infected organs, either through the skin or mucosa, is the most common sexually transmitted infection, placing young women at a high risk of contracting it. Although the vast majority of cases spontaneously clear within 1-2 years, persistent HPV infection remains a serious concern, as it has repeatedly been linked to the development of multiple malignancies, including cervical, anogenital, and oropharyngeal cancers. Additionally, more recent data suggest a harmful effect of HPV infection on pregnancy. As the maternal hormonal environment and immune system undergo significant changes during pregnancy, the persistence of HPV is arguably favored. Various studies have reported an increased risk of adverse pregnancy outcomes among HPV-positive women, with the clinical impact encompassing a range of conditions, including preterm birth, miscarriage, pregnancy-induced hypertensive disorders (PIHD), intrauterine growth restriction (IUGR), low birth weight, the premature rupture of membranes (PROM), and fetal death. Therefore, understanding the mechanisms employed by HPV that negatively impact pregnancy and assessing potential approaches to counteract them would be of interest in the quest to optimize pregnancy outcomes and improve child survival and health.

Clinical significance of serum matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1 in the first phase of burn trauma evolution

No prospective study has specifically examined the serum levels of matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of metalloproteinase-1 (TIMP-1) in the early shock phase of burn-injured patients. Thus, we aimed to detect early changes, activity dynamics, and the predictive value of MMP-9, TIMP-1, and the MMP-9/TIMP-1 ratio to better understand the early repair mechanisms for the development of future therapies for patients with thermal burns. Twenty-five patients with a total body surface area (TBSA) affected by burn <25%, and 30 healthy subjects were enrolled in the study. Serum levels of MMP-9 and TIMP-1 were determined by the ELISA method. Our results showed that MMP-9 concentrations increased immediately after injury and remained on a plateau. In contrast, TIMP-1 showed an upward trend throughout the 7-day study period, and the time course of the MMP-9/TIMP-1 ratio followed the inverse dynamics of TIMP-1. Analysis of the areas under the receiver operating characteristic (ROC) curves (AUC) showed that patients with burn wounds tended to have a MMP-9 value higher than 421.5 ng/ml (AUC=0.979), TIMP-1 value higher than 231.6 ng/ml (AUC=0.908), and MMP-9/TIMP-1 ratio higher than 2.31 (AUC=0.959) (P<0.001). Our findings suggest that although the variations in the two biomarkers were different regarding the time of the initial insult, their ratio is a specific and sensitive indicator of burn evolutivity in patients with a TBSA affected by a burn <25%.

Role and dynamics of matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1 in burn patients

Burn injuries can trigger tissue changes that can explain the variation in the level of different biochemical markers that can be recorded both locally or systemically. Some events observed in burn wounds such as vascular hyperpermeability have been associated with the release of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) after trauma. Because it is unknown whether the serum levels of MMP-9 and TIMP-1 are a consequence of these destructions or a local response to thermal damage, we decided to follow their dynamics. Twenty-five patients (mean age 49.40±17.55 years) with a total body surface area (TBSA) affected by a thermal burn of <25% and 30 healthy subjects (mean age 49.70±8.04 years) were enrolled in the present study. Enzyme immunoassays were used to measure the serum levels of MMP-9 and TIMP-1. Our results showed that MMP-9 was increased 6.25-fold immediately after injury compared to the controls and remained on a plateau throughout the 7-day monitoring period. TIMP-1 showed an upward trend with an increase of 49.52% on the seventh day after triggering insult. The time-course of the MMP-9/TIMP-1 ratio followed the inverse dynamics of TIMP-1 starting from a ratio value measured at admission 3.82-fold higher than the one observed in the healthy volunteers and a highly statistically significant correlation between the values measured at different time-points during the monitoring period (P<0.001). The results of this retrospective study indicate that the MMP-9/TIMP-1 ratio may provide information on local changes over time, starting from the triggering insult, and may be considered as a predictive biomarker of burn evolutivity.

Sentinel Lymph Node Biopsy after Neoadjuvant Treatment for Breast Cancer. The Validation Protocol

Introduction: The identification and biopsy of the sentinel lymph node (SLNB) in breast cancer patients requiring neoadjuvant cytostatic treatment (NAC), with clinically negative lymph nodes following treatment, may be an effective method of de-escalation of axillary surgery. Materials and methods: This prospective study includes 47 cases of breast cancer stage IIB-IIIA, with NAC treatment and complete axillary clinical and imaging response, surgeries performed at Prof. Dr. Alexandru Trestioreanu Oncological Institute in Bucharest (IOB) by the same team. In all the cases, SLNB was employed using the radioactive tracer method. The SLNB technique with Tc99 radioactive tracer involves: - injection of the radioactive tracer and preoperative lymphoscintigraphy, - intraoperative identification of the sentinel node/ lymph nodes and their excisional biopsy, - intraoperative histopathological examination, in paraffin blocks, and immunohistochemistry of the lymph node (SLN). Results: SLN was identified in 46 of 47 cases. In 19 cases SLN was positive, and in 2 cases we recorded false negative results. All patients underwent standard axillary lymphadenectomy (back-up lymphadenectomy). The correlation between the intraoperative and paraffin histopathological examination of SLN with the paraffin and immunohistochemical examination of the rest of the axillary nodes (N-SLN) led to the following results: sensitivity 91% (19/ 21), specificity 100% (25/ 25), positive predictive value 100% (19/ 19), negative predictive value 93% (25/ 27). The accuracy of the method was 96% (44/ 46). SLN invasion was more common in patients with residual tumor 2 cm (vs T 2 cm) (p = 0.01), positive N-SLN (vs non-invaded N-SLN) (p = 0.003). N-SLNs were more frequently invaded when there was peritumoral lymphocyte invasion (vs. no invasion) (p = 0.01). Conclusions: SLNB in patients with breast cancer who require NAC, with clinically and imaging negative lymph nodes following treatment, has a high rate of specificity and an acceptable number of false negative results. Node invasion is more common in patients with residual tumors 2 cm, with lymphovascular invasion or with multicenter/ multifocal disease.

Clinical significance of serum melatonin in predicting the severity of oral squamous cell carcinoma

Melatonin, the primary hormone produced by the pineal gland, is intensely assessed for its anticancer properties. This study aimed to reveal the clinical significance of serum melatonin levels in predicting the severity of oral squamous cell carcinoma (OSCC). For this purpose, 40 male patients with OSCC and 30 healthy subjects were enrolled in this study. The serum levels of melatonin were determined by ELISA. The results revealed that the melatonin concentrations were significantly lower in the patients with OSCC compared with the controls (18.2 vs. 47.6 pg/ml, P<0.001). In addition, the serum melatonin levels had a high predictive accuracy for discriminating patients with OSCC with T-depth of invasion (DOI) II from the healthy controls (89.1%), as well as in discriminating patients with OSCC with nodal metastasis from those without nodal metastasis (83.8%). On the whole, the findings of this study suggest that the serum melatonin concentrations are closely related to the severity of OSCC and may thus be used to assess the different stages of oral cancer objectively and accurately. The present study also supports the conclusion that melatonin may be a potential therapeutic agent for use in the treatment of patients with OSCC.

Breast Cancer Surgery in Images

As a picture speaks more than a thousand words, we tried to reflect, at least in part, on our surgical day-to-day practice on the 2nd Oncological Surgery Department of "Prof. Dr. Al. Trestioreanu" Bucharest Institute of Oncology in the field of breast cancer. And how could we not talk about imaging in breast cancer, when one of the reasons for low breast cancer mortality at present is early detection, which is performed through imaging investigations. Mammographic screening is recognized as a success in this area (Fig. 1), but moreover, mammary ultrasound, a newer addition to this domain, also allows the detection of infraclinical cancers (Fig. 2). The localization of these infraclinical lesions can be obtained preoperatively by mammographic technique using a harpoon (Fig. 3). Under ultrasound guidance we can not only puncture cysts (Fig. 4), but also perform mammary biopsies for suspicious lesions.

Pitfalls in Cutaneous Melanoma Lymphatic Drainage

Sentinel node (SN) biopsy has become standard in staging of cutaneous melanoma. As skin lymphatic drainage is complex, preoperative empirical assessment of SN localization is virtually impossible. Therefore in order to identify all regional lymphatic basins corresponding to a specific primary tumor is mandatory to carry out preoperative lymphoscintigraphy. In this paper we present a clinical case that highlights the importance of identifying, biopsy and histological analysis of all SN in order to achieve a correct staging of the patient, followed by appropriate treatment according to the real clinical stage of the disease.

Clinical significance of the lymphoscintigraphy in the evaluation of non-axillary sentinel lymph node localization in breast cancer

BACKGROUND

Identification and biopsy of the sentinel lymph node (SLN) in early-stage breast cancer (T1-T2N0) has become the standard method in the surgical treatment of the axilla, due to its accuracy in the evaluation of axillary lymph node status,thus avoiding extensive axillary lymph node dissection inpatients with negative SLN. The aim of our study is to highlight the role of 99mTc-nanocolloid lymphoscintigraphy in the preoperative lymphatic mapping, especially for SLN localizations outside the axilla, as well as the benefits of this technique in the accurate staging of breast cancer.

MATERIALS AND METHOD

430 patients (age 31-81 years) with breast cancer (T1-T2N0 stage) were included in the study group, who underwent lymphoscintigraphy in order to identify the sentinel lymph node in the Nuclear Medicine Department of "€œProf. Dr. Al. Trestioreanu"€ Institute of Oncology, Bucharest,between October 2008 - July 2014. Radiocolloid (99mTc-nanocolloid)was injected using peritumoral or periareolar intradermal technique, doses between 20-37 MBq (0.3-0.5 ml volume), followed by static and dynamic post-injection acquisitions.Intraoperative identification of the SLN was performed using a gamma-probe, guided by the skin marker performed preoperatively after completion of lymphoscintigraphy.

RESULTS

697 sentinel lymph nodes were identified through imaging techniques in 427 patients (99%). Of them, 364 patients had axillary localization of the SLN, while 48 patients(11%) had non-axillary (pectoral, internal mammary, supraclavicular,intra-mammary) localization and 15 patients (3%)had multiple localization (axillary and non-axillary).Intraoperative histopathological exam revealed lymphatic invasion in 74 SLN (12% macrometastases and 88% micrometastases).

CONCLUSIONS

The identification and biopsy of the sentinel lymph node in stages I and IIA is a useful routine for accurate breast cancer staging, suited for axillary lymphatic drainage, as well as for unusual non-axillary SLN localization, guiding the clinician for further postoperative management of these patients.

Sentinel lymph node biopsy (SLNB) vs. axillary lymph node dissection (ALND) in the current surgical treatment of early stage breast cancer

The identification and biopsy of the sentinel lymph node has become a standard method of treatment for stage I and II breast cancer in the last decades, taking into account the fact that the management of the axilla in patients with breast cancer has evolved from the routine lymphadenectomy to a selective attitude, based on the histopathological evaluation of the sentinel lymph node, as well as on the tumor and on the patients' characteristics. Since the introduction of the method into clinical practice, in 1994, different methods of identification have been used (radioisotope injection, vital blue dye, or, more recently, lipophilic contrast agent for ultrasound visualization or paramagnetic nanoparticles (NPs) or the method of indocyanine green fluorescence), each presenting certain limits, but the radioisotopic method proving the most accurate. Moreover, during the development of the method, beside the standard indications specific for T1 or T2 breast tumor, without clinical or imagistic axillary adenopathies, their extension to a series of other particular situations such as the following, has been tried: ductal carcinoma in situ, multicentre tumors, after excisional biopsy or tumors preoperatively treated by neoadjuvant chemotherapy. The aim of the paper is to present the progress made regarding the current stage in the use of sentinel lymph node technique in breast cancer, while mentioning the established indications, as well as the ones that are still debating and need further studies. Likewise, the cases in which the axillary lymph node dissection remains the major indication for treatment of the axilla, in patients with early stage breast cancer, will be discussed.

Peculiarities of lymphatic drainage in cutaneous malignant melanoma: clinical experience in 75 cases

In the recent years, the identification and biopsy of the sentinel lymph node (SLN) has become standard in the treatment of cutaneous malignant melanoma (CMM). In order to correctly apply the technique and to decrease the risk of false negatives,it is compulsory to track the lymphatic drainage of the primary tumor and to detect all SLN, regardless of their site.

METHOD

At the Bucharest Oncologic Institute, over the last three years, selective lymphadenectomy was performed in 75 patients with CMM, stages I and II (AJCC). In 39 cases, the primary tumor was at the level of the upper and lower limbs and in 36 on the trunk. In all patients, lymphoscintigraphy was performed through intradermal injection of Nanocoll,with dynamic follow up of the radiotracer, with the purpose of finding the possible unusual locations of the SLN.

RESULTS

The sentinel lymph nodes were identified in 100%of the cases. In 63 patients (84%), the primary tumor drained in only one lymphatic field and in the other 12 the drainage was towards 2 or more lymphatic basins. The CMM situated on the trunk had a particular behaviour, presenting more often (33%) with multiple nodal basin drainage.

CONCLUSIONS

CMM of the trunk, mostly those situated close to the midline, but others as well, tend to drain into several lymphatic areas. The existence of interval lymph nodes and atypical lymphatic drainage, in a minor lymphatic basin,must be determined preoperatively in order to allow the biopsy of all SLN and establish the right therapy.

Occult breast lesion localization and concomitant sentinel lymph node biopsy in early breast cancer (SNOLL)

AIMS

Mammographic screening and the increasing resolution output of mammography have raised the identification number of small-size mammary lesions without clinical expression. The aim of this study was to evaluate in a prospective study the localization techique and concomitent sentinel lymph node biopsy for breast cancer (SNOLL - Sentinel lymph Node biopsy and Occult Lesion Localization).

METHODS

We identified by means of imaging techniques a number of 107 patients with clinically occult suspicious breast tumors. All patients preoperatively underwent a protocol in which the injection of 99mTc-nannocolloid under imaging procedures was performed. Surgical excision was performed, guided by the hand held gammaprobe. The sentinel lymph node was identified as an axillary hot spot on the probe.

RESULTS

All primary lesions were identified and were clear of invasive margins needing excision. 98 tumors proved to be malignant on frozen sections. 7 lesions could not be clearly examined through frozen section and 2 proved to be benign. 6 out of 7 suspicious lesions confirmed to be malignant on parrafin embedded sections. Sentinel lymph node was identified in a number of 95 out of 98 patients. In 14 cases complete axillary lymphadenectomy was performed. The average specimen weight was 40 grams.

CONCLUSIONS

Using this technique, we removed the lesions identified prior to surgery in all cases, achieving a complete pathologic diagnostic, the necessary surgical treatment and also prognostic data by axillary lymph node assessment.

[Latest approaches in the surgical treatment of cutaneous malignant melanoma]

Malignant melanoma is a disease with an unpredictable evolution. Detected in stage I and II has a great chance to cure, if it is correctly treated: excisional biopsy with safety margins in accordance with tumor thickness. Lymphoscintigraphy with sentinel node identification and biopsy became compulsory for staging malignant melanoma, the role of complete lymphadenectomy would be established by publishing the MSLTII data. The sentinel node is analysed using more and more sophisticated techniques (RT-PCR) in order to detect isolated tumoral cells, although their clinical significance is not known yet. Metastases occurrence is a dramatic phenomenon because chemotherapy, radiotherapy or biologic therapy have insignificant results. The only therapeutic modality which may increase survival in this situation is surgery for some carefully selected patients.