Breast-conservative surgery with and without radiotherapy in patients aged 55-75 years with early-stage breast cancer: a prospective, randomized, multicenter trial analysis after 108 months of median follow-up

OBJECTIVES

Breast-conserving therapy (BCT), including postoperative whole breast irradiation (WBI), is generally accepted as the treatment of choice for most patients with early-stage breast cancer. The question whether WBI is mandatory in all patients remains one of the most controversial issues in BCT. To answer this question, a randomized, prospective, multicentre study was launched in January 2001. Primary endpoints of the study were to assess the cumulative incidence of in-breast-recurrences (IBR) and overall survival (OAS) after conservative surgery (BCS) with or without WBI.

METHODS

From January 2001 until December 2005, 749 patients with unifocal infiltrating breast cancer up to 25 mm, 0-3 positive axillary lymph nodes, no extensive intraductal component or lymphvascular invasion from 11 centres in Italy, were randomly assigned to BCS+WBI (arm 1:373 patients) or BCS alone (arm 2:376 patients). Treatment arms were well balanced in terms of baseline characteristics. Systemic adjuvant therapy was administered according to the institutional policies. Kaplan-Meier method was used for survival analysis and log-rank test to evaluate the difference between the two arms. RESULTS (Last analysis 31.12.2012): After median follow-up of 108 months, 12 (3.4%) IBR were observed in arm 1 and 16 (4.4%) in arm 2. OAS was 81.4% in arm 1 and 83.7% in arm 2. There was no statistically significant difference regarding IBR and death in the two treatment groups.

CONCLUSIONS

These data are promising and suggest that WBI after BCS can be omitted in selected patients with early stage breast cancer without exposing them to an increased risk of local recurrence and death. Longer follow-up is needed to further consolidate these results.

Conservative surgery with and without radiotherapy in elderly patients with early-stage breast cancer: a prospective randomised multicentre trial

Breast conserving therapy (BCT) including postoperative irradiation of the remaining breast tissue is generally accepted as the best treatment for the majority of patients with early-stage breast cancer. The question is whether there is a necessity for irradiating all patients. Between 2001 and 2005, 749 women aged 55-75 years with infiltrating breast carcinoma were randomly assigned to breast conservative surgery, with or without radiotherapy (RT), to evaluate the incidence of in-breast recurrence (IBR). After 5 years of median follow-up, the cumulative incidence of IBR was 2.5% in the surgery-only arm and 0.7% in the surgery plus RT arm. There are no differences in terms of overall survival and distant disease-free survival. The preliminary evaluation suggests that breast irradiation after conservative surgery can be avoided without exposing these patients to an increased risk of distant-disease recurrence. Prolonged follow-up will further clarify the possible risks and late sequelae potentially induced by breast RT.

[Splenectomy for hematologic disease. Mini-invasive versus traditional technique]

BACKGROUND

This study aimed to compare the safety, efficacy and clinical benefits of laparoscopic splenectomy (LS) to open splenectomy (OS) in patients with hematologic disorders.

METHODS

EXPERIMENTAL DESIGN

prospective study;

SETTING

II Department of Surgery, Santa Maria Nuova Hospital, Reggio Emilia and III Department of Surgery, Santo Spirito Hospital Pescara;

PATIENTS

48 consecutive adult patients underwent splenectomy; 30 patients under-went LS and 18 OS. Perioperative characteristics, outcomes, complications and costs were comparatively analyzed.

RESULTS

Mean age was 35.3 years in the LS group, and 40.8 in the OS group. Mean spleen size was 11.7 cm in the LS group and 15.2 cm in the OS group. Accessory spleens were found in 5 patients in the LS group and in 4 patients in the OS group; 4 conversions to laparotomy occurred in the LS group. A total of 4 complications occurred in 3 patients of the LS; 9 complications occurred in 5 patients of OS group. Mean surgical time was 141.5 minutes for LS and 89.7 minutes for OS (p<0.005). Mean postsurgical stay was 5.8 days in the LS group and 8.5 days in the OS group (p<0.005). Response rates were similar in both groups.

CONCLUSIONS

LS is comparable to OS in terms of efficacy and safety and it is associated with a shorter hospital stay. LS should become the technique of choice for treatment of intractable benign hematologic disease.

[Extrarenal retroperitoneal angiomyolipoma: description of a case and review of the literature]

A case of retroperitoneal extrarenal angiomyolipoma is described. The patient, a 61-year-old woman, presented with a large retroperitoneal lipomatous mass. Histologically, it consisted of lipomatous tissue. Focally, there was interstitial and perivascular proliferation of bland oval and epithelioid cells with a large, eosinophilic or clear cytoplasm. Immunohistochemically, these elements were positive for smooth muscle actin and HMB-45. The literature on retroperitoneal extrarenal angiomyolipoma is briefly reviewed. It is important that the pathologist recognize this lesion, even when it is located in the retroperitoneum outside the kidney, and differentiate it from a liposarcoma.

[The nasojejunal tube in early postoperative nutrition]

BACKGROUND

To verify the effectiveness of the nasojejunal tube inserted during operation as an alternative to jejunostomy to perform early enteral feeding.

METHODS

EXPERIMENTAL DESIGN

Prospective study.

SETTING

Department of Surgery, General Hospital.

PATIENTS

27 patients undergoing laparotomy because of a gastric pathology.

INTERVENTIONS

In 18 patients before construction of the distal jejunum anastomosis the tube was inserted by nasal route and advanced into the jejunum ansa until the end reached 15 to 20 cm down the anastomosis (group A); 9 patients underwent a jejunostomy according to Delany (group B). All the patients started enteral feeding 24 hours after operation and had the same polymeric diet, given to them using the same procedures.

MEASURES

postoperative complications, tube intolerance, intestinal tolerance.

RESULTS

The degree of non-acceptance of the tube was: absent in 3 patients of group A and in 7 patients of group B (p > 0.05); slight in 6 patients of group A and in 2 patients of group B (p > 0.05); medium in 9 patients of group A and in no one of the group B (p no measurable); high in neither groups. The intestinal tolerance was similar in both groups.

CONCLUSIONS

Nasojejunal tube is an effective alternative to jejunostomy to perform early postoperative enteral feeding.

[Male diabetic mastopathy: description of a case]

A case of diabetic mastopathy in a male is described. The patient is a 44 year old man with an insulin-dependent diabetes of long duration, presenting with a poorly defined nodule in his left breast. The lesion was constituted by a dense fibrous tissue with epithelioid stromal cells and a perivascular nodular lymphoid infiltrate. The differential diagnosis and the literature on diabetic mastopathy are briefly reviewed, particularly regarding male patients. The present case indicates that diabetic mastopathy may arise in the male breast.

Endoscopic protector hood for safe removal of sharp-pointed gastroesophageal foreign bodies

Endoscopic removal of sharp and pointed foreign bodies in the upper gastrointestinal tract still poses technical difficulties. Overtubes may be uncomfortable to the patients and only objects fitting within a lumen of about 11-15 mm can be removed. We present here our preliminary experience with a commercially available new endoscopic end protector hood having the unique characteristic of maintaining its bell portion inverted during the progression of the scope through the gut and flipping back to its original shape during withdrawal through the lower esophageal sphincter. This prevents exposure of the esophageal and pharyngeal wall to injuries from the edges of the foreign body. We used this device to remove nine large sharp or pointed gastroesophageal foreign bodies in six consecutive patients in whom conventional techniques were considered unsafe or not technically feasible owing to the size and shape of the objects. In all cases, removal was successful and easily performed without bowel damage. We believe that this device enhances the safe removal of a wide variety of potentially dangerous gastroesophageal foreign bodies.

Colonoscopic excision of large and giant colorectal polyps. Technical implications and results over eight years

Large polyps are sessile or pedunculated lesions that are larger than or equal to 3 cm in size. Sixty-six colonoscopic piecemeal excisions of large pedunculated and sessile polyps (75 percent of 88 recognized large polyps) were performed over eight years. The macroscopic feature of the lesions and the result of an extensive snare biopsy were the deciding factors for endoscopic as opposed to surgical removal. Only three complications (4.5 percent) were recorded (two hemorrhages and one colonic wall burn syndrome), none of which required surgery. Fifty patients with 52 adenomatous lesions had colonoscopic follow-up (range, 3 to 85 months). Of 36 sessile adenomas, two cases of residual (5.5 percent) and four of recurrent disease (11 percent) were observed. Colonoscopic removal is an alternative to local surgical excision of large benign colorectal polyps, and often can be an alternative method to elective colectomy in elderly and high-risk patients.

Foreign bodies of the biliary tract. Endoscopic management

In the period 1978-1984, 23 patients underwent endoscopic intervention for foreign bodies of the biliary tract. The patients are subdivided into three groups: the first group consists of 11 cases in which the foreign bodies were suture threads, either simple or as a nidus for gallstones; the second group consists of six patients with a sump syndrome of the biliary tract; the third group includes six patients who retained drainage tubes or stents after a biliary tract operation. In our series, endoscopic extraction was performed as a first-choice procedure. The high success rate may favor endoscopy as a low-morbidity, low-mortality approach and as an alternative to a relaparotomy.

[Duodenal ulcer. Gastroscopic aspects before and after acupuncture treatment]

4 cases of duodenal ulcer, diagnosed by gastroscopic examinations three of which were already treated medically with insufficient results, are presented. Acupuncture was carried out several times (about 5 to 7) during 1-2 months and gave rise to a complete disappearance of the clinical symptoms and complete healing of the former lesion was diagnosed through gastroscopy