Analysis of sentinel nodes biopsy in breast cancer--12 years after introduction into clinical practice

INTRODUCTION

Sentinel node biopsy in breast cancer has been a standard procedure at the Institute for Oncology of Vojvodina since 1999 and we have done more than 700 biopsy. Before the introduction of axillary sentinel lymph node biopsy, lymph nodes were routinely dissected, and this approach was the gold standard in surgical treatment of breast cancer. The study was aimed at presenting our results in performing sentinel node biopsy in clinical practice for operative treatment in breast cancer.

MATERIAL AND METHODS

All patients (n = 791) were women with clinically T1-2, N0-1, M0 breast cancer. Sentinel lymph node marking was performed by both contrast blue dye (Patentblau V) and radiotracer (antimony sulfide marked with Tc99m). Both contrast media were applied peritumorally or periareolarly. After sentinel lymph node biopsy all patients underwent breast-conserving surgery or mastectomy with or without lymph node dissection of level I and II (depending on sentinel lymph node status).

RESULTS

Sentinel lymph node biopsy was negative in 543 (68.7%) patients, and positive in 248 (31.3%) patients. Solitary tumor was present in 722 (91.2%) cases, multifocal tumors in 36 (4.57%), multicentric in 28 (3.55%) and bilateral in 5 (0.68%) patients. The mean duration of follow-up was 60.59 months (median 65, range 12-132). Distant metastases were mostly found in bones (39.13%).

CONCLUSION

The number of complications related to axillary dissection can be reduced and the patient's quality of life can be improved by avoiding complete axillary lymph node dissection.

Lung cancer trends in Vojvodina

PURPOSE

Lung cancer in Vojvodina is the leading form of cancer as well as the leading cause of cancer deaths in men. It ranks 2nd in cancer deaths in women in Vojvodina. The goal of this report was to study lung cancer in Vojvodina in th period 1989-1998 by analysing the crude and age-standardized incidence and mortality rates in the male and female population.

MATERIALS AND METHODS

Data used for analyses were provided by the Cancer Registry of Vojvodina from the Institute of Oncology Sremska Kamenica. Data included number of cases and deaths of lung cancer, by age groups in 5 year intervals and by the municipalities for male and female population separately. Descriptive epidemiological method was used.

RESULTS

An increasing tendency of linear trend of lung cancer incidence in males based on crude and age-standardized incidence rates was found. The trend of lung cancer incidence in males was highly intense and extremely unfavorable. In females, an increasing tendency of linear trend of lung cancer incidence based on crude and age-standardized incidence rates was also found; this was not as intense but it was unfavorable. An increasing tendency of linear trend of lung cancer mortality based on crude and age-standardized mortality rates in both sexes was registered, which was not intense, but it was unfavorable.

CONCLUSION

Vojvodina is a region with high incidence and mortality rates in comparison to neighboring and European Union (EU) countries both in male and female population.

Stage IB2 cervical cancer: brachytherapy followed by radical hysterectomy

PURPOSE

Stage IB2 squamous cell cervical cancer can be treated by radiation therapy alone or by radical hysterectomy and lymphadenectomy (pelvic-/+para-aortic). Preoperative radiation therapy followed by extrafascial hysterectomy has been recommended as an effective combined treatment method.

PATIENTS AND METHODS

During the period January 1994-January 2004, 114 patients with stage IB2 cervical cancer were treated with preoperative brachytherapy followed by radical hysterectomy (Piver class III) with pelvic lymphadenectomy.

RESULTS

Histology showed that 56 (49%) patients were without cervical malignant disease. Positive lymph nodes were found in 5 (9%) of them and negative in 51 (91%). In 58 (51%) patients cervical cancer still existed after brachytherapy and among them 26 (45%) were with lymph node metastasis. Patients with residual cervical carcinoma and positive lymph nodes after brachytherapy were older than those with no residual carcinoma and negative lymph nodes.

CONCLUSION

Women with stage IB2 squamous cell cervical cancer primarily treated with brachytherapy must be assessed by appropriate diagnostic procedures to evaluate local effects of brachytherapy and the status outside the pelvis. Negative local findings with positive lymph nodes point to further treatment of patients, while positive local findings point to radical surgery which may increase recurrence-free interval.

Retroperitoneal malignant schwannoma and peritoneal malignant mesothelioma: a case report

Malignant schwannoma and peritoneal malignant mesothelioma (MM) are very rare tumors. Schwannoma or neurilemmoma-benign or malignant-do not arise from the nerves, but from the supporting Schwann cells. Malignant peripheral nerve sheath tumors (MPNSTs) commonly are large in size. They are painful and may cause many different symptoms depending on their location and size. MM arises primarily from the surface serosal cells of the pleural, peritoneal, and pericardial cavities. A malignant schwannoma was diagnosed in a 52-yearold woman, which was surgically treated. After a 17-month disease-free interval, local recurrence was diagnosed. The patient was operated on for second time and MM was diagnosed as second primary tumor, along with recurrence of the malignant schwannoma. The patient received postoperative adjuvant external beam radiotherapy and chemotherapy. Despite combined-modality treatment the disease progressed and the patient was operated on for third time 2.5 years after the first operation with partial tumor resection. She died 3 years after the first diagnosis. Early diagnosis of these two types of tumors is very difficult because of unspecific clinical symptoms. Singlemodality therapy of these tumors has shown poor results. Combined-modality approaches have shown some benefits, but further studies are required.

Amnioreduction in treatment of increased amniotic fluid volume

Introduction Increased amniotic fluid volume may significantly increase the risk for preterm delivery. Amniodrainage is a symptomatic treatment by which excess amniotic fluid is reduced to provide fetal lung maturation. The aim of this study is to estimate the efficacy and safety of this procedure, our results and give a literature review. Material and methods Sonografic criteria were used (AFI> 400 ml, or the biggest amniotic fluid pocket > 150 mm) to choose patients in whom 18G needle was used to allow leaking of excessive amniotic fluid. Results 10 patients underwent 26 procedures. The procedures were performed at 28.6th week gestation, on average and 6.25 weeks average gain or 1000 g. We had two sets of monochorionic twins with twin-to-twin transfusion syndrome (TTTS), where one child survived. One procedure was followed by premature placental abruption, and premature delivery in 28th week. The rest of procedures were uneventful. Conclusion In our series of 10 women, 26 procedures were performed to prolong pregnancies, enable fetal maturation and weight gain. In majority of cases amnioreduction was done without complications, so we could repeat the intervention and prolong the pregnancy. Survival of one child in two TTTS pregnancies should not be regarded unsuccessful in our conditions.

[Ovarian epithelial carcinoma--a malignant disease sparing no age group]

INTRODUCTION

Ovarian epithelial carcinoma is one of the most common gynecologic malignancies and the fifth most frequent cause of cancer death in women. Ovarian cancer affects women 65 years of age and older more frequently than younger women.

MATERIAL AND METHODS

Four young patients with ovarian epithelial carcinoma were treated at the Institute of Oncology in Sremska Kamenica, Serbia and Montenegro, in the period 1981-2000. The median age at diagnosis was 17.3 years. Final histopathological findings revealed cystadenocarcinoma, either mucinous or serous. The stage of the disease was established using International Federation of Gynecology-Obstetrics (FIGO) Calssification. Spread of the disease dictated the extent of operation and post-operative chemotherapy. Patients were strictly followed-up at the Institute.

RESULTS

The first two patients underwent unilateral adnexectomy as initial treatment. Final histopathological examination revealed an epithelial ovarian carcinoma, stage IIIa and IIb. Total hysterectomy with unilateral adnexectomy and total omentectomy were performed in both patients as second treatment with chemotherapy, according to the Cisplatin/Carboplatin and Cyclophos-phamide (CP) protocol following surgery. Another two patients underwent total hysterectomy with bilateral adnexectomy and total omentectomy as initial treatment with chemotherapy, CP protocol, following surgery. Both patients had stage IIc. Despite treatment, in two patients with stage IIIa and IIc, metastases were diagnosed. In 2 patients survival was over five years. One patient lived less than 3 years, and one less than 4 years.

DISCUSSION

Ovarian carcinomas are difficult to diagnose at early stage. Histologic confirmation of the diagnosis, surgical staging, and aggressive surgical debulking, when possible, are all part of the initial evaluation and treatment. In most cases, surgery is followed by chemotherapy. The risk increases from 15.7 to 54 per 100,000 in the age group 40-79 years. Our study included 4 patients, medium age 17.3, with epithelial ovarian carcinoma which warns us to think twice when we get an adolescent patient with an adnexal mass.

CONCLUSION

Advancing age, the major risk factor for development of ovarian carcinoma is, of course, unalterable. We investigated 4 patients medium age 17.3 years, with epithelial ovarian carcinoma. Pelvic masses found in women of reproductive age, must also be evaluated preoperatively to determine the probability of malignancy.

[Amnionic infusion therapy in conditions with low amnionic fluid levels]

INTRODUCTION

Amniotic fluid volume reduction can have serious consequences: prior to 24 gestational weeks hypoplasia of fetal lungs and later in pregnancy cord compression and fetal hypoxia as well as contractions of extremities. Diagnosis of oligohydramnios is made either after a subjective estimation of amniotic fluid reduction or if the biggest amniotic fluid pocket is less than 1 cm. Amnioinfusion is a procedure during which a crystalloid solution, most often saline, is instilled into the amniotic cavity substituting amniotic fluid. To estimate the efficacy and safety of amnioinsfusion using our results and literature review.

MATERIAL AND METHODS

Up to 800 ml of sterile saline solution was instilled intraamniotically (10-15 ml/min) in cases where the amniotic fluid index was less than 10 and intraamniotic infection was excluded. After that, 1 g of Longaceph was given intraamniotically. Infusion was stopped immediately when 800 ml was instilled, if a subjective estimation showed that there was enough fluid or if contractions occurred.

RESULTS

During a six-month period there were five amnioinfusions--four therapeutical and one diagnostic; in four cases the procedure was successful and in one preterm rupture of membranes occurred 20 hours after the procedure. The procedure was most often done in the first half of the third trimester and continuation of pregnancy in successful cases was between 4 and 5 weeks, with average fetal weight gain of about 1200 gr. No complications occurred in cases where pregnancy continued.

CONCLUSION

In our preliminary study amnioinfusion led to prolongation of pregnancy in majority of cases providing better maturation of fetal lungs and higher birth weight, without any complications. Further studies are necessary to reach definite conclusions about the efficacy and safety of amnioinfusion.

[Olfactory perception in women with physiologically altered hormonal status (during pregnancy and menopause]

INTRODUCTION

Olfaction is considered to be the ability to: perceive, conduct and recognize scents and odors. With its numerous connections to the limbic system and reticular formation, the olfactory system affects regulation of numerous vegetative functions, visceral functions and sexual behavior. Since estrogen and progesterone protect the olfactory function, changes in their levels in particular physiological states in women (in pregnancy and posmenopause) exert an influence on the ability to feel and recognize smells. It has its role in creating emotions and adjustment of visceral and vegetative response to particular emotional states. Also, it represents the connection between higher cortical functions and the endocrine system.

MATERIAL AND METHODS

Our investigation was performed at the Ear, Nose and Throat Clinic in Novi Sad. The research included 80 healthy women classified into 4 groups; 20 women aged between 20 and 30; 20 women in the first trimester of pregnancy aged between 20 and 30; 20 premenopausal women aged between 41 and 50; and 20 women at least 3 years in postmenopause, aged between 41 and 50. For our research we used an olfactometer and the Fortunato-Niccolini method.

RESULTS AND DISCUSSION

In pregnancy the thresholds of perception (TP) and identification (TI) of examined substances were slightly lower in comparison to nonpregnant women of the same ages, but without any statistical significance (p > 0.05). In climacteric-postmenopausal women there was a significant decrease of olfactory ability in comparison to nonmenopausal women of the same ages (p < 0.01).

CONCLUSION

All changes of the olfactory function in pregnancy are explained by mental changes of pregnant women as well as their hormonal status. Significant decrease of olfactory ability in postemnopause is explained by decline in sexual hormone levels.

Radical hysterectomy for stage IB1 cervical carcinoma: lymph node metastasis as a prognostic factor

PURPOSE

Lymph node metastasis is one of the most important factors influencing prognosis and further therapy in patients with cervical carcinoma. The aim of this study was to confirm the impact of nodal metastasis od disease-free interval in women with stage IB1 cancer of the uterine cervix.

PATIENTS AND METHODS

From June 1986 to December 1999 269 patients with stage IB1 cervical carcinoma were operated on. Two hundred thirty-six (87.84%) patients had class III and 33 (12.16%) class II radical hysterectomy, according to Piver's classification.

RESULTS

The median number of the removed lymph nodes was 21. Positive lymph nodes were found in 71 (25.28%) patients. All patients with positive lymph nodes received postoperative adjuvant external beam radiotherapy. Patients with bulky nodal disease received also chemotherapy.Overall 5-year disease-free interval in 212 patients was 80%. Five-year disease-free interval for patients without lymph node metastasis was 91%, while it was 40% in those with lymph node metastasis (p < 0.0001).

CONCLUSION

Surgical staging of cervical cancer, which includes pelvic and para-aortic lymphadenectomy,together with pathological data, can provide potentially useful information for the radiation oncologist and precise analysis of survival and prognostic risk factors.

[Treatment protocol for cervical carcinoma]

INTRODUCTION

Cervical cancer is the second most common cancer in women worldwide and the second cause of cancer death among women. About 95% (90% in developed countries) of invasive carcinomas are of squamous types, and 5% (10% in developed countries) are adenocarcinomas. FIGO classification of cervical carcinomas, based on clinical staging and prognostic factor dictate therapeutic procedures and help in designing treatment protocols.

THERAPEUTIC MODALITIES

Surgical therapy includes conization, radical hysterectomy with pelvic lymphadenectomy and palliative operation--urinary diversion and colostomy. Radiotherapy, brachytherapy and teletherapy are most recently combined with chemotherapy as concurrent chemoradiation.

DISCUSSION AND CONCLUSION

No change in therapeutic modalities will ever decrease mortality rate of cervical carcinoma as much as education, prevention and early screening. The 5-year survival for locally advanced disease has not improved during the last 40 years as a result of failure to deliver therapy to the paraaortic region. Paraaortic lymph nodes should be evaluated before therapy planning by different imaging procedures, or more exactly by surgical staging: laparoscopy or laparotomy. Radical operations of cervical carcinoma should be performed by experienced surgeons, educated for this type of operation, with sufficient number of cases.

Benign and malignant struma ovarii: report of three cases and review of the literature

Struma ovarii belongs to the group of monodermal and highly specialized teratomas and comprises less than 5% of mature teratomas. Thyroid tissue is present exclusively or predominantly. Malignant transformation in struma ovarii is uncommon, and when present, it exhibits a follicular pattern most of the times. Three patients with the diagnosis of struma ovarii are presented herein. Two of them had a unilateral adnexal mass with ascites in one case. Total abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy were carried out in both patients. In both patients thyroid hormonal status was normal pre and postoperatively. The third patient had a histology compatible with follicular carcinoma of the thyroid tissue of struma ovarii; strumal carcinoid was also present. Postoperatively monochemotherapy with etoposide was administered for 6 cycles every 3 weeks. Thyroid hormones and thyroid ultrasonography (US) were also normal in this patient. Surgical management is the treatment of choice for struma ovarii which also represents a preventive measure for possible future malignant transformation.

Tumor angiogenesis in gynecological oncology

Angiogenesis, the formation of new blood vessel networks to permit sustained tumor growth, is one of the most rapidly growing fields in basic and applied cancer research. Angiogenesis is a prerequisite for tumor growth and metastasis. Vascular endothelial cell proliferation, migration and capillary formation are stimulated by angiogenic growth factors. It is now accepted, mainly on the basis of knock-out experiments, that the most potent pro-angiogenic factor is the vascular endothelial growth factor (VEGF). VEGF is the prototype of a family of pro-angiogenic peptides, which now comprises several related members. Recent studies in gynecological oncology have shown considerable importance of tumor angiogenesis as independent prognostic factor, or the use of angiogenesis-related factors as possible tumor markers. Immunohistochemical studies have revealed that high microvessel density (MVD) was associated with poor prognosis in carcinomas of the uterine cervix, endometrium, vulva and ovary. Tumor angiogenesis is not a specific process for one type of tumor, and angiogenic growth factors cannot be specific for one type of malignant disease. Immunohistochemical studies also showed importance of angiogenic factors and MVD in other kinds of cancers such as breast cancer, gastrointestinal cancers, soft-tissue sarcomas etc. The importance of tumor angiogenesis in the natural history of cancer, the possible applications of angiogenesis markers as prognostic factors and the emergence of innovative antitumor treatments based on anti-angiogenic strategies may lead to new goals in oncology.

Effects of cadA gene on cell division phenotype

Studying cell division regulatory mechanisms in Escherichia coli an important role of cad operon was discovered. The cadA gene is part of the cad operon. The promotor of cad operon (pBA) regulates two genes, cadB (the first gene in the cad operon) and cadA (the second one). The cadB encodes the lysine-cadaverine antiporter. The cadA gene encodes enzyme lysine decarboxylase that turns lysine into cadaverine and carbon dioxide. The expression of cadA is activated by several different environmental parameters, such as low pH, low oxygen, and excess lysine. Regulation of any of these parameters depends on the presence of cadC gene, encoding the regulator of the operon. It is located upstream of cad operon. The aim of this study is to investigate if the effect upon the cell division rate was caused by the induction of cadA. Specific aims were to obtain structural gene of cadA and construct a plasmid (pAM1) that contains cadA under the control of the arabinose inducibile promoter pARA, and complement the cell division phenotype of a cadA mutant by providing cadA on the inducibile plasmid. Activation of the pAM1 with 0.05% arabinose reduced the cell division rate that confirms the inhibitory effect of the pAM1.

Percutaneous pancreatography under ultrasonographic guidance

PURPOSE

The aim of the study was to evaluate percutaneous pancreatography as an alternative method for pancreatic duct visualisation in patients with pancreatic disease.

MATERIAL AND METHODS

In 21 patients with pancreatic disease and previously unsuccessful ERCP, puncture of the pancreatic duct was carried out under ultrasonographic guidance with an 0.7-mm Chiba needle, and contrast injection was made under fluoroscopic control in the pancreatic duct.

RESULTS

The procedure was successful in 18 patients (86%). In 10 patients, chronic pancreatitis was found, and in 8 patients, pancreatic carcinoma.

CONCLUSION

Percutaneous pancreatography is a good alternative method for visualisation of the pancreatic duct in patients with pancreatic disease and previously unsuccessful ERCP.