Refining neutropenia risk assessment in patients treated with first-line endocrine therapy (ET) and cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) for metastatic breast cancer (MBC) through a cell-free DNA workflow (cfDNA)

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Background: The combination of ET and CDK4/6i is the current standard of care for hormone receptor (HR)-positive/HER2-negative MBC (luminal MBC), with neutropenia being the main dose limiting toxicity. We previously observed the potential association between leucocyte count (WBC) and different fractions of cell free circulating DNA (cfDNA) (Bortot et al 2020). The present study aimed to evaluate the feasibility of a cfDNA-based workflow as a new tool to assess the risk of treatment induced neutropenia. Methods: The study analyzed a prospective cohort 83 luminal MBC patients (pts) treated with first line ET and CDK4/6i in the CRO-2018-56 multicenter study from 2018 to 2021. cfDNA was characterized through droplet digital PCR (ddPCR) based on different ACTB DNA fragments lengths: short (s), medium (m) and long (l). Blood samples were collected before treatment start (BL) and at the first clinical evaluation after 3 months (E1). Associations between clinical characteristics, neutropenia and cfDNA were explored through Kruskal Wallis, time to G3 neutropenia (NG3) (TTN) was analyzed through log-rank and Cox regression. Results: Neutropenia was G3 in 44 out of 83 pts (53%) and G4 in 2 pts (2%). Median TTN was 1.8 months, 60% of NG3 occurred within 3.7 months. Overall, 74 pts (89%) resolved toxicity within 7 days, 10 pts (12%) reduced CDK4/6i dose after NG3. BL neutrophils count (Neu) and WBC were significantly lower in pts that developed NG3 (P = 0.0013 and P = 0.0020 respectively). De novo metastatic pts had numerically higher Neu (median 4825 vs 3895), but only a numerically lower risk of NG3 was observed (HR 0.53 P = 0.064). Although bone involvement was not associated with risk of developing NG3, the total number of metastatic lesions was associated with higher NG3 (P = 0.0016). In particular, > 5 metastatic lesions were associated with higher NG3 risk (p = 0.013). E1 ACTB_m was significantly lower with respect to BL in pts that experienced NG3 (median 100% vs 16%, P = 0.0136 in NG3 no vs yes) with a consistent impact on the risk of NG3 (HR: 2.81, P = 0.025). No associations were observed for the other ACTB fragment length fractions. BL Neu and ACTB_m dichotomized at the median were then combined to describe 4 distinct TTN risk groups (P = 0.0006). Interestingly, pts with low BL Neu and low E1 ACTB_m had a median TTN of 0.9 months, while pts with high BL Neu and high E1 ACTB_m have not experienced NG3 after a median follow-up of 16.1 months. Conclusions: The present study proofed the concept of using cfDNA to provide clinically meaningful data not only about tumor biology, but also for a comprehensive patient assessment. Based on these results, a prospective study focused on a multiparametric neutropenia risk assessment will be started.

Laparoscopic transabdominal preperitoneal (TAPP) hernia repair: surgical phases and complications

BACKGROUND

This study aimed to determine the nature of complications after transabdominal preperitoneal (TAPP) hernia repair, and to evaluate possible links to intraoperative factors in an effort to reduce the incidence of complications.

METHODS

The TAPP procedures for inguinal/femoral hernias performed between 1992 and 2004 at a single center were analyzed retrospectively. Complications were categorized according to severity and stage of the surgical procedure at which they occurred. Individual surgeon performances were examined to determine whether the rates of complications were related to surgeon experience.

RESULTS

A total of 1,973 TAPP procedures were reviewed, and 81% of the patients completed 5 years of follow-up evaluation. The 74 complications (3.7%) reported were categorized as follows: 33 major (1.7%) versus 41 minor (2.0%), 66 hernia-related (3.4%) versus 8 laparoscopy-related (0.5%) complications, and 12 recurrences (0.6%). Risk factors for complications included inguinoscrotal hernia (p < or = 0.001), dissection/reduction of the sac (p = 0.02), and surgeon experience (< 50 TAPP procedures; odds ratio, 7.1; 95% confidence interval, 4.2-11.9).

CONCLUSIONS

Accuracy in dissection/reduction of the sac improves the outcome of TAPP hernia repair. This effect is related to the experience of the surgeon. Experience performing more than 75 procedures is required for optimal results.

[Cholecystolithotomy with cholecystojejunostomy as surgical solution for cholelithiasis in portal hypertension caused by hepatic cirrhosis]

Cholecystolithotomy and cholecystojejunostomy has been carried out on 11 patients with severe hypertension from cirrhosis. The indications were frequently recurring attacks of biliary cholic or acute cholecystitis at onset. There was 1 postoperative death from cardiac infarction and only minor in-hospital morbidity. None of the remaining patients has to date developed post-cholecystojejunostomy sequelae. Except the case of extensive inflammation on gangrena, this procedure appears to be a safe and definitive operation, alternative to subtotal cholecystectomy.

Pancreatic malignant melanoma with occult primary lesion. A case report

A case of unusual location of a M.M. in the head of pancreas is described. Evidence of a primary lesion was not achieved, still we incline to retain this case as a metastatic malignant melanoma with occult primary location.

[Bronchogenic carcinoma (personal observations)]

The authors report the results achieved in the treatment of 62 patients with pulmonary cancer "non-microcytoma". The survival rate was 20.9% at 5 years (actuarial). The best prognosis is for patients with epidermoid cancer: 35.5%. The authors emphasize the importance of the exact stage of the neoplasm and the evaluation of the postoperative cardiopulmonary functional adaptation in the prognostic evaluation of resection for pulmonary carcinoma.

[Lipid cell carcinoma of the breast]

A review of cases treated in 1978-82 revealed 1 case of lipid cell carcinoma of the breast out of 310 mammary carcinomas. Given the rarity of this histological type and the generally poorer than average prognosis, it seems likely that it should be considered separately from the other cases.

[Recurrent anorectal abscesses]

A study of 78 patients with recurrent anorectal abscess was carried out to elucidate the cause of recurrence. The inadequate treatment (incision and drainage) and the spontaneous rupture or resolution of the abscess with no further treatment were the most common reasons for recurrence. At surgery, 18 patients were found to have recurrent hidradenitis suppurativa. The authors recommend a careful regional exploration under anesthesia and an aggressive surgical approach to achieve satisfactory results and to ensure minimal, if any recurrence.

[Transduodenal papillosphincterotomy. Remarks on 138 cases (1975-1982)]

Transduodenal papillosphincterotomy, largely performed since many years, is still controversial. The retrospective analysis of 138 cases allows a discussion about its indications and some important details of surgical technique. Particularly, the authors report a relative low incidence of serious complications, with peculiar regard to postsurgical acute pancreatitis, and satisfactory long-term results (follow-up ranging from one to eight years) in the 95,2% of cases.